13 ALBION ST - BPA-13-626 2 NEW K&B'S, TRIM & DOORS The Commonwealth of Massachusetts F
O
Board of Building Regulations and Standards CITY ITYSAL
Massachusetts State Building Code, 780 CNIR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For'Official Use Only
Building Permit Number: : Date Apph
Building Official(Print Name) 1 .Signature
SECTION 1: SITE INFORN TI
Property 1 1.2 Assessor ap & Parcel Numbers
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Publict Private❑ Zone: _ Outside Flooit Zone? Municipal IX On site disposal system ❑
Check if yes❑
g SECTION2:,`PROPERTY'OWNERSHW-' `
2 d.
p C J
nertofReg � t -4 U1CLO 7Z^�/ tiC 7 S
Name(Print) I/ .µ.�,� p ,y�- City,State,ZIP
/(o&- ;2kj_-3_ t9-BC,Y(
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK''(check all that apply)
New Construction ❑ Existing Building< Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) )!f Addition ❑
Demolition El Accessory Bldg. ❑ Number of Units o2 Other ❑ Specify:
Brief Description of Proposed Work':
e.�.✓ v •-` oo
SECTION 4: ESTINIA'TED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only,., -
Labor and Materials
1. Building S SO L Building Permit Fee S Indicate how fee is determined;
❑ Standard City/Town Application Fee
2. Electrical S a d O ❑Total Project Cost' (Item 6)x multiplier x
3. Plumbing S v d O 2 Other Fees:
4. Mechanical (FIVAQ S %O p O List: I
5. Mechanical (fire $
Suppression) "fatal All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S a �vC) 0 0 Paid in Full ❑ Outstanding 13ulnrice Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(((CSL) �S - J
L `C.0 S-ar-. License Number Expiration Date
Nameot'CSL— Holder�—
t �1 List CSL Type(see below)
—2 G +C �y r YP
e Description .
No. and Street
U Unrestricted(Bu
ildings s up to 35,000 cu. ft.
C) t R Restricted 1&2 Family Dwelling
City/Town,State,ZIP NI Masonr
RC Roofing Covering
WS Window and Siding
4 fza'pt G t-60 w SP Solid Fuel Burning Appliances
G� ;Z a7.0PA_J6'72� t�� r rOh I Insulation
"1'cle hone Email address D Demolition
5.2 Registered Home Urov Znt Contractor(HIC)
�/ HIC Registration Number Expiration Date
IIIC Company Name or HIC Registrant Name
No. and Street Email address
City/Town, State,ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 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 Owner's Name(Electronic Signature) Date
SECTION 7h: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or An and Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty fund under NLO.L. c. 142A. Other important information on the HIC Program can be found at
www.niass.<,ovioea Information on the Construction Supervisor License can be found at www.massso�'dvS'
2. When substantial wmk is planned, provide the information below:
Total floor area(sq. R.) _(including garage, finished basement/attics, decks or porch)
GrOS.i living area(sq. ft.) _ Flabitable room count
Number of fireplaces- -- Number of bedrooms
Number of bathrooms Number of halfibaths _
I)-pe of heating system _ ---__ Number of decks/ —
I'ypeofcoolingsyswni —_---- Fnclosed_ Open .— _
i3 Foal Pntject Square Poota,e finny be substinded Cor It'otnl Project Cost" ---