22 BELLEAU RD - BPA-2009-595 WINDOWS ga The Commonwealth of Massachusetts
' Board of Building Regulations and Standards FOR
- Massachusetts State Building Code,780 CMR, 7`' edition MUNICIPALITY
QBuilding Permit Application To Construct, Repair, Renovate Or Demolish a RevfsedJanuary "
One-or Two-Family DwelZing 1, 2008
This Sectio r Official JUse Only
Building Permit Numb D#e Ap lied:
Signature l 3f 3�fA
. Building Commissioner spectorofBu ings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
�a � el�w:. 2c1 SC,1e,&,. AAA- ,,,ci
1.1 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 8) Frontage(ft)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Requind Provided Required Provided -
1.6 Water Supply: (M.G.L c.40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?.Public❑' Private❑ — Municipal❑ On site disposal system ❑
' Check ifyes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
<"e'lem 'PAP, olglo
Name(Print) Address for Service: _
Cl -1 1.4.S— �-f (o t(o
-Signature - Telephone -
SECTION 3-.DESCRIPTION OF PROPOSED WORK{ (check all that apply)'
n�m....•'yCasuu4: Ex C Demolition ❑ Accessory Bldg: ❑ TJumber of I hrits Other O S.pceiry:_"
Brief Description of Proposed Work'-: lf� V. de e w
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I.Building $ l 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard 6ty/Town Application Fee
❑Total Project Cos? (Item 6)x multiplier x
3.Plumbing $ 0 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) 6 Total All Fees: $
c Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 0 <j; l ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
C15Zc) D
�r- a✓\ License Number Expiration Date. r
Name of CSL-Holder List CSL Type(see below) Lt
-
ddress T e ;.::; Descri lion . . .
_ _ _AIC
U Unrestricted(n to 35,000 Cu.Ft '
- R Restricted 1&2 Family y Dwelling
Signature
- Ol.Lot -o riot a M Masonry Only
RC Residential Roofing Covering - -
Telephone. WS Residential Window and Siding -
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition '
�-2 Registered Home Improvement C ntractor(HIC) - oI
�✓�ec a1 1ny � t�Ie �-f�c niS '>7
HIC Company Name or HIC RegistranF Name Registration Number _
10 I D I :S St nJ >rf ��ou vtiAA 0LrJ'>
-
" !i-04 i d Expiration Date
Signature Telephone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.GS..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 .,........ IY No...........❑
SECTION 7a: OWNER4ITT,HORIZATIONTOBE•COMPLETED,
OWNER'S AGENT,OA<60?e B 4CTOR APPLIES FORBIRLDIlV6 PERNSiT
h 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.
Signature of Owner Date '
SECTION 7b:.OWNER'OR AUTHOR17Ek';D W ENT AE;CLAR 4IION
} i4~• �. 2�2 S ne Guvet or - rt crized A t bt'Fkbv Berl
tl a( Che statemen—Ls and efonnaho11 on the foregcin+apptr�ation atefrue and accurate to �e best of m;k So-4ledbe and
behalf. .
VIA
tea.
Signature ofOwner o ri a Date(Signed underthe pains and penalties of a 'u
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 and
Construction Supervisor Licensing(CSL) can be found in 780'CMR Regulations 11 O.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
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 ofhalffbaths
Type of heating system Number of decks/porches '
Type of cooling system Enclosed Open
L. "Total Project Square Footage"may be substituted for"Total Project Cost"