19 ARTHUR ST - BPA-13-1010 REPAIR DECK 1. r
e The Commonwealth of Massachusett Crys
` Board of Building Regulations and Standards SAL OF
1 Massachusetts State Building Code, 730 CNIR SdMar[
� Revised Mar 2011
1 Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section Forofficial USa Ord
Building Permit Number: Date Applied;.
Building Official(Print Name) ignati re.'
SECTION I:SITE INFO IO
L1 Property AdJress: 1.2 Assessors Map 8t Parcel Numbers
)9 �j
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: 1.3 Sewage Disposal System:
Public❑ Private Cl Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesC1
S> CTIONZ, PROPERTY-OWNERSH7PL
2.1 �wnerroPRecad: � 5
✓vas•+ ftz �. iyia r�ig�v _
Name(Print) City,State,ZIP -
/) A77q(t,iZ S�
No.and Street Telephone -Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORle(check all t at apply):
New Construction ❑ Existing Building❑ Owner-Occupied ❑ I Repairs(s) UYf Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. Cl Number of Units_ Other. ❑ Specify:
Brief scriptia(g\of ProposedWork3: e .nG /aX/cam Dt�e__C_
la f4�� tl J�4Y14,�
SECTION is ESTINLATED CONSTRUCTION COSTS-
Item Estimated Costs: Official Use Only:.
Labor and Materials
I. Building S LSD I..Building Permit Fee-.S Indicate how fee is determined:
Electrical ❑Standard.CityCCuwn•ApplicationFe'e.'
2. ❑'Cotal Project Cost(Itern.6)x multiplier x
3. Plumbing > 2. Other Fees: $
t. M-chanical (11VAC) S List: �4.
i. Mechanical (fire S
5n >pression) _ "Cotal:Ul Fees:.S_
Check No. _Check Amount: ____Cash Amount:.
n fuml Project [' itC S �/ ❑ Paid in Pill Cl Outstanding Valance I)ua:
r
SEcrION 5: CO:NS'rRUCrION SERVICES
5,1 o struction Supervisor License(CSL)
r it- C� v` °y License Nurnber epir,lion Daro
Name ofCSLIfolder List CSL'rype(ice beluw)
16 v'f J*fe Type Description
No. and Street
U Unrestricted Duildin s u to J3,000 cu. 11.
�� ����- R Restricted 13r2F;unil Dwollin
citylrovvn, State,ZIP VI Masonr
RC Rootin Cuverin
WS WindowundSiding
SF Solid Fuel Durning Appliances
-�u4 Z c� C��zycrJ'r7 Cr'
y -f I Insulation
I'ele hune Email address D Demolition
5.2 Re I ered Home Improvement Contractor(11IC) 1 ;7 l l
r;to /,I flIC Registration Number xpt�ratiun Da—ie
I IIC Cuinpany FJnma yr(IIC Rcgi�nt Nmna
No.and tjeet 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 ..........per No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO DE 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 by this building permit application.
Print Owncr's More(Electronic Signature) - Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
B
yame below, I hereby attest under the pains and penalties of perjury that all of the information
pplication is true and accurate to the best of my knowledge and understanding.
`uthurired:\;ent'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
(nut registered in the Home Improvement Contractor(HIC) Program),will Prot have access to the arbitration
program or guaranty bold under M.G.L. c. 142A. Other important information on the HIC Program can be found at
,vww.m;u>.eue:%oca Information on the Construction Supervisor License can be found at w%—% %V ru .eIa dL
2. When substantial work is planned,provide the information below:
Total floor area(sq. It.) _(including garage, finished bascrrtendattics, decks or porch)
dross living area(ml d.) tfabictblc room count
Number of fireplaces.-.—_------ Number of bedrooms
Numhcrufbativ,,,ntt; NumbcrafhalG'baths ----_---- —
fcpeofhc.uing ;y;trm —_--._-- Namhcrofde�k.,,' pnrehas
- ------
I\pa ofeanlingry�tcm fiuclosed open
t. I,v.il l egret iyu ire 1:1wrl-'t ui.ty he ;nb;tinurd t:)i ,t.il l'nijert Co;t"