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35 ANDREW ST - BPA-10-669 ROOF 0/ '00 The Commonwealth of Massachusetts CITY �{ t Board of Building Regulations and Standards +. ' Massachusetts State Building Code, 780 CMR, 7'"edition OF SALF.M v Revised Junuury Building Permit Application To Construct,Repair, Renovate Or Demolish a f. ?Doti I e-or Two-Family Dw ling W� This Section For O ial Use Only r I Building Permit N r. ate Applied: ':L L l7 IWIIII Signature: `[ ` �4- t J Ruildinj Commissioner/Ins t I gs Date �Hf7TIION 1:SITE INFORMATION 1.1 Pro ert,,��yrr Address: 1.2 Assessors Map& Parcel Numbers C1n/f�12.ac4J Si- - I.la 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 R) Frontage(It) 1.5 Building Setbacks(fl) 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: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public O Private❑ Check if es❑ P po y SECTION 2: PROPERTY OWNERSHIP' 2.1 Ownert of Record: .�`C'�2�>ir \/ 1Vl✓I xL !L- 2 S 1e1•,-a P-o%J s r Name(Print) Address for Service: 9-) R 4 9 R I z-_D..q Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORKt(check all that apply) New Construction❑ Existing Buildin wner-Occupi pairs(s) ❑ Alteration(s) O Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work': SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building S I. Building Permit Fee:S Indicate how fee is determined: 2. Electrical S ❑Standard Cityrrown Application Fee ❑Total Project Cost (Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (IIVAC) S List: 5. Mechanical (Fire S Suppression) Total All Fees:S e Check No._Check Amount: Cash Amount: 6.Total Project Cost: S 9, LA _ 3 001-` 0 Paid in Full 0 Outstanding Balance Due: SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) © � ` ; y� (0 t7"Z' bi'tJS License Number Expiration Date Name ol'CSL-Ilolder !✓�._._�. List CSL'f)pe(seebelow),A17iu AJJ s f pe Descri Lion U Unrestricted(up to 35,000 Cu.Ft. R Restricted 1&2 Family Dwelling Sig •ture g� `; ODResidential son Only `� ^S 1 �3 \ idential Roofing Covering fclephone idential Window and Siding idential Solid Fuel Burning Appliance Installation Demolition 5.2 Regbtered F�ome Improvemefl Contractor(HIC) © Q �j -.-QnJ l -t.b_c. I--1r 4tY"T— Ra _spl N p Registration NumberIIIC Cmu r � ICt 6-23 AJJ ss p -7 C� k� Expiration Date Signature Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,4 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...........O 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. Signature of Owner Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION as Owner or uthorized Agent ereby 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 of Owner o uthorized Agent Date (Signed under the ains an na ttes of 'u 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 gg 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 I IO.R6 and I IO.RS,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 J. 'Total Project Square Footage"may be substituted for"Total Project Cost"