26 BELLEAU RD - BPA-2010-34 SHED T, • .j
The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7ih edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Ttso-Family Dwelling
This Section For Official Use Only
Building Permit Nu ber:
Date Applied: 'v
Signature:
Building Com rssioner/Inspecmr of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Prop¢e1rty/Address• �� 1.2 Assessors Map& Parcel Numbers O 3 l I
ri.J.� 4�Q1 ..._. � 2
Ma Number Parcel Number
i.la Is this ar:accepted street?yes (/ no P
1.3 Zoning Information: 1.4 Property Dimensions:
C 7-4Zoning District Proposed Use Lot Aka sq—fL) Frontal ( )
LS Building Setbacks(ft)
t Front Yard
Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.(j.L C.40,934) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zo e? Municipal On site disposal system ❑
l7/Publics Private ❑ Check if esf� 1]'
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner ofRScord•
. n� ✓r���yy,,�,
AN e(Print) Address for Service:
Sin ture Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction]E3tExtisting Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑Demolition ry Bldg.l7/ Number of Units . O her ❑ Specify:
Brief Description of Proposed Work': 1.. ®�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Ofliclal Use Only
Item Labor and Materials
I. Building S Q 0
I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S —'' ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (BVAC) S List:
S. Mechanical (Fire S Total All Fees: S
Suppression)
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: S y eo 13 Paid in Full 13 Outstanding Balance Due:
4 f
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Nme of CSL-Hplder
List CSL Type(see below)
Address Type Description
U Unrestricted u to 35.000 Cu. Ft.)
Signature R Restricted I&2 Famt!�rlhng
M Mason OnlRC Residential Roofin n
WSResidential Windowdin
SF Residential Solid Fuel Burning Appliance Installation
D I 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. 152.1 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
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 Date
SECTION 7b: OWNER OR AUTHORIZED AGENT DECLARATION
I• ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Nlime
f7..�,vr,a . —/rYl
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
r
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 I 10.116 and 110.R5, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/artics,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
�. "Total Project Syuare Footage"may be substituted for"Total Project Cost'