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12 BEACON ST - BPA-2009-299 PELLET STOVE , The Commonwealth of Massachusetts h i Board of Building Regulations and Standards Town of v / Massachusetts State Building Code, 780 CMR, 7'" edition Wilbraham Building Dept Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800 One-or Two-Family Dwelling Ext 118 )Jiis Section For Official Use Only c Building Permit Nu er: d. Date Applied: t ' (J O Signature: lo- b , 0 Cl Building Commi!Q*r/`!qi0ector of Buildings Date SECTION 1:SITE INFORMATION t.l Proee�rty Address: So.V! 1.2 Assessors Map& Parcel Numbers ` mME1 1.1 a Is this an accepted street?yes ✓ no Map Number Parcel Number 1.3 Zoning Information: 1 -4-Pr;ape:-ty^i:ren,-fd^s: Zonmg 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.t,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Pubic ❑ Private❑ Zone: Outside Flood Zone? — Municipal ❑ On site disposal system ❑ _ Check if yes❑ _ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: X �(- \z©�'� z�s �a {3e�,co�.� S�t�of„ Mtn ola -0 Namur(Print) Address for Sen•ice: - �-1�5--1�-1 t-I-Cr�co 31 Sig attire Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units 2. Other ❑ Specify:_-_ Brief Descrip+io;;of Proposed Work': , . 0 -__Q _�^�?:`. - __ -� SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical g ❑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: $ 3�)00 0 Paid in Full 0 Outstanding Balance'Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) License Number Expiration Date N Name of CSL-Holder List CSL Type(see below) s Type Description Address U Unrestricted(up to 35,000 Cu.Ft. R Restricted 1&2 Family Dwelling Signature M Masonry Only RC Residential Roofing Coccri_n Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Company Name or HIC Registrant Name Registration Number Address Expiration Date Signature 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 th;s 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 prop=Ay Grreby authorize to act on my beha!t; in all matters relative to work authorized by this building permit application. I Signature of Owner Date _ Q,� SECTION 7b: OWNER OR AUTHORIZED AGENT DECLARATION I"��f` as 2� Owner or Authorized Agent hereby declare r� , that the sta+rments and i ormati n the foregoing application are true and accurate, to the best of my knowledge and i behalf. Print Name PC - --TT�D Signature of Owner o.Authorized Agent Date (Signed under the pains and penalties ofperjury) NOTES: 1. An Owner who,.tbtains 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 N4 G.L. c. 142A.Other important information on the HIC Program and Construction Supervisor Licensing(CSi.)can be found in 780 CMR Regulations I IO.R6 and 110.R5, respectively. 2. When substantial work is ulanned,provide the information belov.: Total floors 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 halfibaths 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"