2 AUBURN RD - BPA-16-463 SIDING Zl� Cr- t 59 1 S
The Commonwealth of Massachusetts
a Board of Building Regulations and Standards CITY OF
SA
Massachusetts State Building Code, 780 CMR
Revised Mar Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
9 One-or Two-Family Dwelling
_.
This Section Section For Official Use Only
Building Permit Number: Date Applie
=9 A^
( Building Official(Print Name) Signature r Date
SECTION 1: SITE INFORMATION, r
1.1 Property Addres : 1.2 Assessors Map&Parcel NumbersJP
1.1a Is this an accepted street. yes no Map Number Parcel Number pry
cY-
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: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP`
2.1 Ow III
ne�r o� Record:
Name(Pint) City,State,ZIT
g rn 6rig
No.and Sheet Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units oth$E e Spec'
Brief Description of Proposed Work':
GG
• SECTION 4:ESTIMATED CONSTRUCTION COSTS V
Estimated Costs
Item Official_Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee: $ 't'ndicate how fee is determined:,
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cose.(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $ "
4. Mechanical (ITVAC) $ List: ,
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check AinoiLnt ' Cash Amount
6. Total Project Cost: $ , ❑Paid in Full ❑Outstanding Balance Due:
�ul �Iit� S
SECTION 5: CONSTRUCTION SERVICES
5.1 Cons coon Supervisor License(CSL)
License Number'Expr on Date
Name a L lder Type
( )
List CSL T e see below
No. freer Type - Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City ow ,S to M Mason
ry
4 do
RC Roofing Covering
WS Window and Siding
❑ non Supervis s rgnature or ectronic Signature) SF Solid Fuel Burning Appliances
I I Insulation
Tee hone Email address D " Demolition
5.2 Registeredi game Irt>f ' vemen Contractor(HIC)
HIC Regis "atto N ber Ex ' mn Date
HI v y Na ut Mhrt
N2Nt )HIC Registrant's Signature
City/Town,State,ZIP Tee hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c..152.§ 25C(6))
Workers Compensation Insurance affidavit must be corn feted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR
APPLIES FOR BUILDINGPERMIT
I,as Owner of the subject property,hereby authorize ( .,� �([ to act on
my behalf,in all matters relative to work authorized by this building permti application.
Owner's Signature or(Electronic Signature) - at
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By tering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
ap lie io is tr an accurate to the best of my knowledge and understanding.
1.
is or A thorized Agent's Name or(Electronic Signature) Dafe
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 can be found at www.mass.Qovioca
Information on the Construction Supervisor License can be found at www.mass.trov/dos
2. When substantial work is planned,provide the information below:
Total floor 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"maybe substituted for"Total Project Cost"
BUILDING • PLANNING HEALTH • ELECTRICAL GAS • PLUMBING • MAINTENANCE