3 AMES ST - BPA-15-735 RESHINGLE REAR HOUSE �l , � ✓ y✓ -D IV
The Conunonwealth of iViassachusetts lot ::N CITY fY OF OF
Board of Building Regulations and Standards SAWN
n Massachusetts State Building Code, 730 CMR 11 5 �UL ReL . r? l
�I
Building Permit Application"Ib Construct, Repair, Renovate Or Demo a
One-or Two-Family Dwelling
f\ This Section For official se Only .
U ' Date plied:
Building Permit Number.
.. Signature- ' V.
Building Otticial(Print None).
SECTION.I:SITE INFORMATION
L2 Assessors Drop 3t Parcel Number
1,1 Property Address'
r Map Number Parcel Number
j` 1.1 a Is this an accepted street. yes 110
1.3 Zoning information: 1.4 Property Dimensions:
---- Lot Area(sy tt) Frontage(It)
Zoning District Propose)Use
1.5 Building Setbacks(ft) side Yams Rear Yard
Front Yard Required Provided
ProviJeJ Required Provided 9
Required ,
1.6\Voter Supply:(M.G.L C.11 J0,§5y) 1.7 Flood Zone Information: LS Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site Disposal system ❑
Public❑ Private❑ Check if es❑
SECTION 2: PROPERTY O\VNERSH�
------------
2.1 Ovyoer'om,ecord.
r"L
�hme(Print) �-• d L -�� 9�,
3 �-i72°S S / • — Telephone L•mail A-
T
No.mid Street
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg.
❑ Number of Units_ Other ❑ Specify:
Brief Descr'tion of Proposed Work': 3
r
SECTION STIDIATED CONSTR CTION COSTS
Estiinated Casts: Official Use Only
Item Labor and Materials
S b i pudding Permit Fee:S indicate how fee is determined: '
I. ❑wilding ❑Standard city/Town Application Fee
. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. other Fees: li-
d. `Icch;mical IHV;\C)
S List:
j. ;\leah:utical (Fire .� Total All Fees:S
suppression) Check Nu._Check Antaunt: Cuh:\nunmt:
6. Total Project Cost: S 7 Q ❑Paid in Full c]Outstanding Balance Due:
f
a
SECTION S: CONSTRUCrION SERVICES
5.1 e tstru on Su''+' /'lI sogtLic��•t(t (C'$L)
�(/l r � QY/J License Number Expiration Date
Name o f C S L Holder
jQ P List CSL'fype(see below) (t
19 a Y7
No. ;cod Suyct
C/ 'rype Description
U Unrestricted(Buildings tip to 35,000 cu. It.
R I Restricted 1&2 Family Dwelling
C ayfl'own,State,ZIP M I Mason
ry
RC Rooting Coven.
mt
WS Window and Siding
SF Soli)Fuel burning Appliances
I Insulation
'Tole hone Email address D Demolition
S. li.,sterecl H,ome(br_iprove/pto Contractor(I IC) -Too ,� t
t Y'P✓ I✓I LfifiTcLN tl; fy71I�CI1 MiL,V1 r
HIC Registration Number :xpuulion Date (
HI ' m y Name mo or IIIC Reg t INnme
�d L� Yr t✓� P
No d�St�e
f/ A,a ry Email address
Cit /Tuwn,State nl ZIP r1 Telephone al
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c, I52. ¢ 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 I _
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Pont Owner's Nmne(Electronic Signature ate
SECTION 7b: 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.
Prii t l wnerS or,\uthorized \gent's N;u e(Electronic Signature) f❑ta
NOTES:
1. An Owner who obtains a building permit to Jo his/her own work,or an owner who(tires an unregistered contractor
(not registered in the Honte Improvement Contractor(FI(C) Program), will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the FIIC Program can be fount at
www.mass.�•ov'oca Information on the Construction Supervisor License can be found at www.mass.eov!JL
2. \Vhen substantial work is planned, provide the information below:
Total floor area(sy. R.) (including garage, finished basement/attics,decks or porch)
truss living area(sq. R.) Habitable room count j
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
'rype of heating systun Number of decks/porches
Fypc of Cooling systant Enclose) Qpen
1. "Ibml Project Square Footage" may be substituted for'`fot:d Project Cost"