40 AURORA LN - BPA-15-1222 FIVE WINDOWS c�25O° GK to-710
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vJ The Commonwealth of Massachusetts IN RECF
Board of Building Regulations and Standards SPEC I�plFt�4 YrOF
Massachusetts State Building Code, 780 CMR
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1 rt Revised Mar 2017 $Building Permit Application To Construct,Repair,Renovate Or DemAs po -S
One-or Two-Family Dwelling
This Section For Official Use Pnly
Building Permit Number: Date Applied: 7) Z
Building Official(Print Name) ` "Signalize - Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
t�2lf�lza rl�a- �4
L l a Is this an accepted street?yes --,-no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSMP'
2. Owner'of Record,
►ZAq. �o�4n(SFs(
Name(Print) City,State,ZIP
LID Al,rto✓tt- LAI �775 z3- -/2�7
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)'
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) lJ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work: 1
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials
1.Building 1. Building Permit Fee:$ Indicate bow fee is determined:
❑Standard City/Town Application Fee
2.Electrical u
3.Plumbing
❑Total eest Costs(Item 6)x multiplied �F : �.
$ � 2. Other Fees: $
4.Mechanical (HVAC) $ List: "
5.Mechanical (Fire
Suppression) Total All Fees:$ -
Cheek No. Check Amount: Cash Amount:
6.Total Project Cost: $ .3 O"Do 0 pad in Full 0 Outstanding Balance bue:
SECTION 5: CONSTRUCTION SERVICES
r5.1 Construction Supervisor License(CSL) ,q �—J F.S-3 `Q
License Number Expiration Date
Name off CSLLFolder
List CSL Type(see below)
No.and Street Description
LC! tip- Q1k3 2 Unrestricted uii su 35,000 cu.ft.
R Restricted l&2 Family Dwelling
Cityfrown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5. eg•stered}Tome Improvement Contractor(HIC) 1 6�a,7
kj pnI oCkk,�S HIC Registration Number Expiration Date
HIC Com any Name or HIC Registrant Name
Mck2
No and Street Email address
l -c.t��-6EcG1 rt'y- n!e�•L �-'78.7.65-?ass—
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NLG.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 .........bC No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR AP/PLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize P (/_ * k�f-IV/aO-rtii
to act on my behalf,in all matters relative to work authorized by this building permit application.
Cak.t-tcL
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Punt Owner's or Authorized Agent's Name(Electronic Signature) Date
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
wzvw.mass.eov,'oca Information on the Construction Supervisor License can be found at www.mass.,>ov/dns
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"may be substituted for"Total Project Cost"