12 ANDOVER ST - BPA-16-420 INSULATION The Commonwealth of Massachu GEIVE.O
,y Q �,ES,TIOHAQ SEf?'JIL r; CITY OF
Board of Building Regulations and Stan ar s CITY
O
K`t Massachusetts State Building Code, 78 CMR
Revised Mar 21111
Of
Building Permit Application To Construct, Repair,Renova?c e`94mA s1 a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number. Date Aof i d:
-
-� Building Official(Print Name) Signature - - Date
1 SECTION 1:SITE INFORMATION
1.1 Property A dr s: 1.2 Assessors Map&Parcel Numbers
L l 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 /I
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP`
2.1 Owne 'of R cord:
Name(Print) City,Stale,ZIP
1.3 I
No.and STreet ' ele� Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORle(check 5A that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) R1Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Oth ❑ S ecify:
Brief Description of Proposed Work-:
S
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
i.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Pown Application Fee
2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $ .
4.Mechanical (HVAC) $ List: C �9
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $
' ❑Paid in Full ❑Outstanding Balance Due:
MAtt�ts^n ( Z
SECTION'S: CONSTRUCTION-SERVICES a-
5.1 Licensed Construc -aA Supervisor(CSL)
Licen e Numtie� ExW= 4;��
Name of Holder
List CSL Type(see below)
Addres T e�': 1 - Description -- -
U Unrestricted to 35,000 Cu.FL)
go R Restricted 1&2 FamilyDwelling
M MasonryOnl
Teleph ne RC Residential RoofingCovering
Sri ndt�v,
WS Residential Window and Sidin
SF Residential Solid Fuel Bumin liance Installation
D Residential Demolition
5.2 Registered o to@ xe ent ntractor(MC)
i�
HIC Co Name or Re stra N e / Regi patio Numb�-�
Addres _
� Exp on ate
Jtgirat6 Tel on
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§'25C(6))
Workers Compensation Insurance affidavit must be compj9ted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance a building permit.
Signed Affidavit Attached? Yes .......... No ........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING,PERNIIT
l> 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.
Signature of Owner Date
SECTION 7b: OWNER'OR:AUTHORIZED AGENT DECLARATION
I> ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature o er AuthorizedAgent Da[
S good under the pailis and penalties of
NOTES:
1. 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 M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 I O.R6 and I IO.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(Sq.Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"