BAKERS ISLAND - BUILDING INSPECTION (18) I I The Commonwealth of Massachusetts
t 4 (o-OOO CITY OF
ilrml:Of Building Regulations and StandarilirCEIVED
Massachusetts State Building Code,10 w L- SERVICE Revised EMar 2011
Building Permit Application To Construct,Repair,Renovate Or Dem lisl�t.a3
One-or Two-Family Dwelling k0S 29 1
This Section For Official Use Only -
Building Permit Number: Date plied:
y
Building Official(Print Name) - Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Addres ' , 1.2 Assessors Map &ParceIN um b s
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Lla Is this an accepted street?yeses no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
M I7 8 ACRfi 4
Zoning District Proposed Use Lot Area(sq It) 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 Owner'of Record:
MA-SSk. FAmiL-V TrLJSY" LFln&A1SJ2�J Ay+ 01913
Name(Print) City,State,ZIP
10 GACK /Ztvf(L !LO q-W Z39 4'71V y1-r&L6co4SMLS7V0la5,
No.and Street 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_ Other Specify:
Brief Description of Proposed Work': 2k/M0✓IL + &F-PC44C . ASPHALT IL00 SH/AALLS
OA! F2oA)T - 0 A /W*, 4,00 401-yuoo4 .SH647741A)6 d- AAtiv/mg;_sHc11_6.
2CM0t/2-t aZCN-Ar� 3 AJ/a1001VS 4- 1kO A SH1NhLtLS OA) SC 07-f 510L>
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 3000 , 00 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ Standard City/Town Application Fee
Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 300c) Paid in Full Outstanding Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street hype Description
U Unrestricted(Buildin s u2 to 35,000 cu.ft.)
City/Town,State,ZIP R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor (HIC)
H
HIC Company Name or HIC Registrant Name IC Registration Number Expiration Date
No.and Street
Email address
City/Town,State,ZI 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 .......... No...........
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.
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.
F
Print 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
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.ma:s.<,ov/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"may be substituted for"Total Project Cost"