4 BECKFORD ST - BPA-14-451 REMODEL KITCHEN file cat 9-
K k�
nmomvealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 730 CNIR SALENI
° Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised.Vfar 2011
One-or TWO-Fmnily Dwelling
This Section For Otiicial Use Only.
Building Permit Number:
Date Applied:
� r
DuilJing Otiicial(Print N;une), �Z �'
ignatpre Date
1.1 Property Address:
SECTION 1:SITE INFOR,NIAT
- -
y Qeck(C Orr 1.2 Assessors iSlap& Parcel Numbers
I.I a Is this an accepted street?yes no_ Map Numbcr
Parcel Numbcr
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed sUe
Lot Area(sy ft) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Site Yams
Provided Re
Required Provide) Rear Yard
Required wired
y Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information:
Public Iry Private❑ Zone: _ Outside Flood Zone? 1.9 Sewage Disposal System:
Check ifyes❑ Municipal DV6n site disposal system ❑
2.1 Owner'of Record: SECTION2: PROPERTY OWNERSHIP'
Orne(Print) Jcdtnr M� O/,7-)o
City,State,ZIP
LlST �7 -77y
trio,and Strut Gq
Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied 21 Repairs(s) ❑ I AIteration(s) C� Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units
Brief Description of Proposed Work': Other ❑ Specify:
SECTION d: ESTINIATED CONSTRUCTION COSTS
Item Estimated Casts:
Labor and,Materials Official Use Only
I. Building $ �s ODO I, Building Permit Fee:$ indicate how fee is determined:
?. Electrical $ 13 ❑Standard City/Town Application Fee
3. Plumbing ❑Total Project Cost'(Item 6)x multiplier? .$ ,x
^ \
4. ��Icchm,ical (IIVAC) $ - Other Fees: �k
5. Mechanical (Fire List:
Su ression) S Total All Fees:S
6. Total Project Cost: S 'y ) Check No._Check Amount:
Cash Amount:_
1 ❑Paid in Full ❑Outstanding Balance Due:
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) License Number Expiration Date
a. e - Ph ll i s 1
Name of CSL HolderList CSL'fype(sae below)
Type..- Description
No. and Street U Unrestricted III In s u l0 35,000 cu. tlJ
/ ,,^G, / It Restricted I&2 .,mil Uwellin
1 4 M Mason
Citylfown,State,LIP RC Roolin Covering
WS Window and Siding
� SP Solid Fuel Burning Appliances
I Insulation
y7�ry Y/7 D Demolition
Tele hone Email a ddress
5.2 Registered Home improvement Contractor(HIC) HIC Registrationr Expiration Date
GII Q 4 '
I IIC Company Name or/IIC� gistrant Na
�_ � c- Email address
No.and Street S �rJr-7�y_O�"Y'2-
/1 ' /✓1c ,Jq2i
Tele hone
Ci Town,State,ZIP
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(V C' 15F Fair to(provide
Workers Compensation Insurance affidavit must be completed and submitted with this application.
this aftdavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..........L'9�
No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CO NTRACTORAPPLIES FOR BUILDING PERMIT
. .� ��✓1!
1,as Owner of the subject property,hereby authorize permit application.
t1 act oil my behalf,in all matters relative to work authorized by this building p '
Date
p n
Frin[Owner's Nmue(Electronic Signature)
SECTION 7ti:OWNERtAR 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. 2 /J
Date
Print wner's or Authorized Agent's Name(Electronic Signature)
NOTESr
will not have access to the arbitration
I. 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)PIngram),
program or guaranty fund under bLG.L.C. I42A.Other important information on the HIC Program can be found at
www.mass.,oy�( a Information on the Construction Supervisor License can be found at wsvw m_='+"�x''`It?s
2• When substantial work is planned,provide the information inldinglgarage,finished basement attics,decks or porch)
total door area(sq. ftJ Habitable room count
Gross living area(sq. ft.)____._----- Number of bedrooms
Number of fireplaces Number ofhalf/baths
Number of bathrooms Number of decks/porches�—
rype of heating system ---- Enclosed —Open
'type orcooling system
3. "fotal Project Square FGoarge"may 11 substituted for,,total Project Cost"
I
L'r Id I
r. I —�-
-_� FN �.. I io 3A
� S '
-.. .. , ._
N
or
!
0 I'Il t 4 1
It
. k �__ - .�. L r -? -- `-�
V6 �
If
64
r _ (
- _
9 0 1
_-.L-
I I I i
I '
I I
I
' I
I I I
-�-,�r,3 4-
u _I. I
h l
! n w.�N
tAL
ir
I i i � --- '_ , � ✓1'�tr.5f5jh✓2no� Oj. S ._) j ! _- . _
i