10 ADAMS ST - BPA-12-894 POOL, RETAINING WALL ti w'
I'lie C'unununweallh uf,blassarhwclts
Pinard ul'Building Regulations and Standards CITY OF
UY sl ; Massachusetts State Building Code, 730 CMR S \LI:,\I
ti Rerieril.ILu•
Building Permit Application To Construct, Repair. Renovate Or Demolish a
One- or rat u-P'anull Un rllhnv
This Section Fur Official Use Only
Building Permit Numlber:
�scN-9Nf,(, t—t/'riLZylGecslG� --
1161ding OBlcial(Print Mum) v Jtgnatu DOIC
SECTION 1:SITE INF RIIIATION
t.l Property Address: 1.3 Assessors Alap& Pure umbers
1.1a Is this on aces ted street? es no Map NumK-r Ilurcel Nunthcr
1.3 Zoning Information: 1.4 Property Dlmenslons:
Luning District I'mpused fisc Lot Area IN 11) Frontage(11)
1.5 Building Setbacks(III
Front Yard Side Yards Rear Yurl
Required 11rovidud Required Provided Requim-d Provided
1.6 Water Supply:(M.G.I.c. 40, 134) 1.7 Flood Zone Information: I.3 Sewage Disposal System:
I IMI:O Private O Zone: _ Outside Flood Zone? Municipal O On site disposal s)seam O
Check if csO
SECTION]: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
N;une(Prinl) Ciq•,Staw,l.IP
Nu.and Sereel telephone Fmuil Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O E.risting Building O Owner-Occupied O Repairs(s) O 1 Alteration(s) Addition O
Demolition O Accessory Bldg.O Number of Units_ Other O ipccily:
Brief Description of Proposed Work': k1s`r:�a t � � !13
��r
SECTION J: ESTIMATED CONSTRUCTION COSTS
lteitt Estimated Costs: Official Use Only
I l.ahur and .\laterialsl
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
l eclrical S O Standard City-?won Application Fee
- O Total Project Costl(Item 6).r multiplier _ r
1. Pluwhing S ?• Olher Fees: S
4. \Ic:h.utic.d ,11\ W) S List:._
9 \IcJmnw.d IFne
tiutvessionl rotal .\itrces: S_
ChaA No. ('hak:\nunnn: l',uh \nunuu:
n Tidal Project Cast: S ❑ Paid in Full 17 Owstanding Ilal mce Doc:
w �
SECHONS: CONSFRUcTIONSERVICTS
5.1 ('unslructiun Supen'isor License(C'SI.)
I i"11,c Numhcr _... - - I:,piraliou Patc
N.unc ol'C'SL I IolJer
Isll'SLI)pel,echclu,.1.-_._ _
-------- ---------- . ._._._..----- 1')pe Dcsrripliun
l� 14tnsuieteJ I RuilJin�s ti m 15,11110 rel. Il.l
R Ite,nicted Ll2 F.unil Dwcllin
Cirri Men.Sl;nc.LII' MI Mason
RC Ravin Opo ,: in
K'S N'induw.u'j tiidin
SF Sulid Fuel Ilurning Appliances
1 insulation
lblc hone Entail❑JJress D Demolition
S.1 Registered Ilume Improvement Contractor(HIC)
IIIC'ItcgislraWn Numl+cr lispinuiun Uuro
I lIC Conlpan) None or I IIC ltegtstrunt Name
No. std Sued ii mail address
Ci /Town, State ZIP role hung
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.1.c. I52.§ 1SC(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this atlidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..........O No...........O
SECTION 7s: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property,hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Uwnei s Nwnc(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,l hereby attest under the pains and penalties of perjury that all of the information
1colained inti aWioue and accurate to the best of my knowledge and understanding.
er'du iNamelhleclrunicSignalurol - -- —D�It`
NOTES:
I. An Otatcr sshu obtains a building permit to do hisher own work,or an owner who hires an unregistered contractor
Inst registered in the Hunte Improvement Contractor IHIC) Program).will1 have access to the arbitration
program or guar;uuy fund under.M.G.L.c. Other important information on the HIC Program can be liwnd at
w,,,, 111.r•, �;„ +.1 Informatiun on the Cunstruction Supervisor License can be found at t,w„ nl.l•' �Io\ 'll+,
2. \\lien substantial work is planned, pros ide the information below:
rola) flour arca 144. 11.1 . __ (including garage. lmished basement attics.'Jecks or porch)
Bross lining area 154. tl.t ..--... _ _ Habitable room coma
\imilier of hedroums
\un+hcrol'hadvvoms . . . . . \lumbcrkit'hall'h;uhs
I'.pc of heating >),tem Xumher of decks. porches
I'1 pc��f Q�Phllg (ll,ell
i\,Ielll I!Ilel, sed
t. Total Project S,luare Footage' may I,c,,,b,iiwtcJ flor ,Total Project Coll"