16 ALBION ST - BPA-14-549 ROOF 1��
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-� 'file Commonwealth of Massachusetts
Board Of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 730 CNIR SALEiSI
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised blur 2011
One-or Tivo-Family Dwelling
This Section For OtTicial Use Only
Building Permit Number:
ate A lied
BuilJing Otlicial(Print Name).
-. -: ignat e, ate
SECTION L•SITE INFORM TION'
1.1 pr per %dress: �1 eiM
10 n S� I^"Gn_( 1.2 Assessors blap g parcel Numbers
thi
I.1 a Is s an accepted street?yes no Map p Number uatber Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use
Lut Area(sy It) Frontage(It)
LS Building Setbacks(ft)
Front Yard Site Yams
Required Rear Yard q Provide) Reyuircd Provided
Required Provided
1.6 Water Supply:(M.G.Le.40,§54) 1.7 Fload Zone Information:
Public❑ Private❑ Zone: _ Outside Flood Zone? 1.8 Sewage Disposal System:
Check ifyes❑ Municipal ❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.11- Owner'of Record: _ I /�
S✓a0rb C'laai'tl n '.SO PD16
Nshme(I ant) � �!✓1 ��C�ZQ ooi�
cny,staIC,z,P
No.mtJ stnu ST 75'1_ 4aQ 9_C67
Telephone L'mail Address
SECTION 3: DESCRIPTION OF PROPOSED 1VORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units
BriefAesc 'ption of ropos d Work': %T` Other ,Rr specify:
SECTION.{: ESTIMATED LuMbi KUCTION COSTS
Item Estimated Costs:
Labor and iNlmerials) Offieial Use Only
I. Building $ 1. Building permit Fee:$ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
3. Plumbing ❑Total Project Cost'(Item 6)x multiplier x
I. Other Fees: $
4. ,Mechmtical (HVAC) $ List.
5. i\lecI- ical (Fire
Su ression) '$ To"'All Fees:S
6, Tutai Project Cost $ 7 d oa Check No._Check Amount Cash Amount:_
❑Paid in Full ❑Outstanding Balance Due:
MAIL, 7 AVIVe�;;;11
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supetvis r License(CSL) License Number Expiration Yale
t
Name ol'CSL Holder List CSL'fype(see below)III All ^�� ��( Type' Description .
Nu.and Street U Unrestricted(Buildin s u to 35,000 cu.tlJ
ON 7S Resuicled I&2Famil Dwellin
JA Ytv ,M Mason
Cityfrown,State,ZIP RC Rootin Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
I insulation
Gnail address
D Demolition
'rcle-- -- _
hone 'a
5.2 Regrste ed Home Improvement Contractor(HIC) /� x iration ate
'VIA HICRegistmtionNumber P
111c Con,p:m�N,pme uorr/ll[Cltegistrunt Name
yy 7G��"` ,11a i D/ Email address
No. Sa
Mo ra 1 ( f�re
le h ne 70U�
/(/9=�--—�—
ro hone
0 Cit /Town,State,ZIP
SECTION 6c WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 152.§ 25C(6)).
itted with this application. Failure to provide
Workers Compensation Insurance affidavit must be completed and subm
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..........F—
No...........❑
SECTION 7a:OWNER AUTHORIZATION.TO BE COMPLETED W HEN
OWNER'S AGENT OR CONTRACTORAPPLIES FOR BUILDING PERMIT'
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Dale
Print Owner's Nmne(Electronic Signature)
SECTION 7b:OWNER'OR AUTHORIZED AGENT TION
DECLARA
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
a plication is rue and accurate to the best of my knowledge and understanding.
contained in thisa/ )
ale
P wner's or Authorized Agents Name(Llcctmnic Signature)
NOTES:
I. An owner who obtains a building perm it to do his/her own work,or anvotwnell )fvhaoetac access to ires an thearbitration
(not registered in the Home Improvement Contractor(HIC)Pro-ram),
program
vogr m or guaranty fund Infomvnfimn on the Constru tioonlSuperver isor Licertant nse can be found mation on the lat%vProg'amycanvbeibund a[
When substantial work is planned,provide the information uinglgar'age, finished basement/attics,decks or porch)
'rota) floor area(sq. ft.) Habitable room count
Gross living area(sq. R.)__.___---- Number of bedrooms
Number of fireplaces Number of half/baths
Number of bathrooms Number of decks/porches
Type of heating system Enclosed—_Open
'type of cooling system
}, Total Project Square Footage"unay be substituted for"total Project Cost"