19 ARTHUR ST - BPA-13-894 RPR WATER DAMAGE HOUSE REAR `���'•Ott ���� �j~>G-s-�a
The Commonwealth of Vassachusetts CCrY OF
Board of Building Regulations and Standards
SALE
Massachusetts State Building Code, 730 CMR
Revised filar
2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This SectionFbrOfficial Usa Only'
Building Permit Number:;'. D.afe hedr,. .
Building Official(Print Si Signaturd.: i Date
SECTION 1:SITE INFORNIATION
LI Property Address: 1,2 Assessors biap& Parcel Numbers
1.1a 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 It) Frontage(it)
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: 1.8 Sewage Disposal System:
Public❑ Private❑" Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes13 .
SECTIONZ; PROPERtY'OWNERSHIPt
2.1 Ownert of Recor
Lh'VieGCL_
Name(Print) City,State,ZIP .
/I '%7L
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF.PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied C7 I Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: .
Brief Description of Proposed Work': -ssx 19' ® n.f .Z3x,%�_.c yzwc, 4247 /"&IT6'
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only,,..
Labor and Materials
I. Building S c?> I. Building PermitFee:S � tidicatehow fee is determined:
2. rlectrical S ❑Standard."CityCPownApplicationFee '
❑"Coral Project Cost',(Item.6)x mu►tiplier x
3. Plumbing S 2. OtherFies:*S
t. Mechanical (IIVAQ S List:
. Mechanical (Fira S 'l'otal All Fees:.S
5ii p rossion)
Check No. Check Amount: Cash Anwuur.
n l'ntal Project CosC S t)ep ---
S f (] Paid in Pull ❑Outstanding Balance Ihta:
SECTION 5: CO:Ns'i-RUCTION SERVICES
5.1HSICIoill
upervisor Licceense(CSL) 475__o8 e-67_
License Number Ex oatiun uteN:un List CSL Type(see below)
Gs7at. G �� Type Description
No. and Street
U Unrestricted l3uildin s u to 35,000 w. lt.
>irL6�. iriA O/�Y70 R Restricted Tii F;unil Dwcllin
City/Town,State, ZIP �[ i\lasonr
RC Rootin Cuvcrin
WS Window and Sidin
SF Solid Fuel Burning Appliances
fxl- sy-Z�/C� � C3UrCa7rh�j � t��-rlit I Insulation ,
Nlc huac Email u"ress U Demolition
5.2 Registered Harrte Improvement Contractor(H[C) /39" C- / 3 i3
1- J form L).9 _ - EIIC Registration Number E.epirui n Uate
1IIC Company Nut a ur EIIC Registrant Name
/o ��,zl�, u sue- C'c jogVrLnr:+4t a' /'owrc4c
No.and eet Ema' address j
City/ wn 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 .......... Off' No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PEMNIff
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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By renteringe below, I hereby attest under the pains and penalties of perjury that all of the information
plication is tru nd accurate to the best of my knowledge and understanding,
' �urimd:\;ent's Name(Elcetronic Siguahoz)
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 r gistered in the Home Improvement Contractor(H[C) Program), will Prot have access to the arbitration
program or guaranty find under M.G.L. c. 142A. Other important information an the HIC Program can be found at
www m:u3.�av%oca Information on the Construction Supervisor License can be found at%kwwjrmss�rM, w
2. When substantial work is planned,provide the information below:
rot i floor area(ml. It.) _(including garage, tinislied basement(attics,decks or porch)
Grosi living❑rea(sq. (1) _ Elabituble room count _
Number of tirep[aces_.--__----- Number of bedrooms ---_-------_--_--
>lumbcrotb.uhroons Numberafhaltbaths --_— —
I* of heating sy;tent . --___-- \umber ufdecks/ porches - -------
f peofconlin� ;y;tci❑ Enclosed pen
;ub;tinicd tar_ I'rnjra l_o-t----