BAKERS ISLAND - BUILDING INSPECTION (33) 4
's
The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY M
Massachusetts State Building Code,780 CMR S
Revised Mar
Mar 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
q This Sectiqjy1ror Official Use Only
Building Perot'_ umber: Date Applied:
�1131�Y
Building O wial(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
�gll�.-�S lSCn.vcl � '000 7
_ Lla Is this an accepted street?yes no Map Number Pazcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
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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 19 Zone: _ Outside Flood Zone? Municipal❑ On site disposal system IN
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
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Name(Print) City,State,ZIP
63 /a3N/Fleeyec 12d. 6D3-897- 9oss- SC&7..sA19C4MC4+Ti--�/c�
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) JS Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of ProposedWork2: RGicli foot- Ja..�.J -c<�/e. � Ijrt. grAj,f
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $l 0 ✓!'c) OO 1. Building Permit Fee:S 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: $ ❑paid in Full ❑Outstanding Balance Due:
4o
ki err"',tL l Z q .
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 1191
Q1 n.Z ' 20
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JAOICS sT l ` /�S' License Number Expiration Date
Name of CSL Holder V
9 / List CSL Type(see below)
6 !.A61--CNCG
No.and Street Type Description
'AG`/1 ^ J�� o O�� U Unrestricted Buildin s u to 35,000 cu.ft.)
N! g(M lG r 1 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP 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)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street 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 ..........❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
,1
1,as Owner of the subject property,hereby authorize
to act on my behalf,in all matte•s relative to work authorized by this building permit application.
t ner's Name(Electronic Signature) Date
SECTION 7b:OWNER'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 f my knowledge and understanding.
Print Owner's or Authorized �Vmcectronic 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. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/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'
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