22 BELLEAU RD - BPA-2009-283 2 WINDOWS The Commonwealth of Massachusetts FOR
Board of Building Regulations and Standards MUNICIPALITY
Massachusetts State Building Code,780 CMR, 7°'edition USE
pp4_� Building Permit Application To Construct, Repair, Renovate Or Demolish a RevisedJanuory
One-or Two-Family Dwelling 1, 2008
�l This Section For Official Use Only
Building Permit Number: Date Applied:
Signature:
Building Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.I Prop ty dress: 1.2 Assessors Map &Parcel Numbers
1a V;ss- 9 _54efn
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 fi) Frontage(fi)
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:
Zone: _ Outside Flood Zone?" Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑ P
SECTION 2: PROPERTY OWNERSFJPL
2. Owl er'of Record- a a /1 I
�Y�h l� rnlorN IJeI eou Rd ��r�em 61920
Name(Print) f Address for Service:
Signature - Telephone
SECTION 3:.DESCRIPTION OF PROPOSED WORK"(check all that apply)
:\eV.'YC:]SCiCCt:Q: ❑ EAIS...�,.alJli.11.lc❑ :)'. Occupied ❑ Repairs(s, . "� ..uc.:(s) ❑ Add--::C. ❑ .
Demolition ❑ AccessoryBldg. ❑ Number ofllnits.--"-.- Other ❑ $pccilS... . ...... _....---.._--
Brief Description of Proposed Work'': tLQ ot cl d
0 S 4-AJ6 `Pt' ✓t /�,
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ (� 3 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑.Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ —
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees: $
Su ression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ vt 3 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed C Mjk
tion Supervisor(CSL) %d 1 / �t
'� ! License Number Expiration Date _
Name of CSL-Hot er
List CSL Type(see below)
A r ss _ - Type Description - -- `
U Unrestricted(up to 35,000 Cu.Ft.) _
Signature R Restricted 1&2 FamilyDwelling -
�, gig _0 �a M MasonryOnly
Telephone. RC Residential RoofingCovering
WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D _Residential Demolition -
5d2 Registered Hoa Int ove ent Con ractor(H /IGH
,K-P J1 c .t t'1,nadn rS..j Seuffi .NI 111'1�4rr `[ toa/
HIC Company Name or SC Registrant N Registration Number
b �t �a play 11a
A dr ss
Expiration Date
- ignature 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 ........... (r No........... ❑
SECTION 7a:,OWNER A'IITHORIZATION TO BE COMPLETED WHEN`. .
OWNER'S AG'NT 0R:CONTRAC.TOR APPLIES FoRSUSLDIN'G'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.
Signature of Owner -
SECTION 7b:;OWNER' OR AUTHORI?,ED AGENTAI;A3IOlu
asY�ttroer or:Au toYtz?d At en . .ehy rtecla;e
dint the shtemenls and in on the f�:_�uin apphcaLun are free and accurate, to the +�st o my k low ledbe and
belial .. �`. ..
.Print I me
g
. .
Si lure 'fOwner or utho Date
-
(Si ed under the ains an alties of au
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 liave 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 I I 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 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"