10 BENGAL LN - BPA-2008-814 BATHROOM, 1ST FLOOR ��,y� -��ao -� ��.1'.3
� The Commonwe•rlth of M•rssachusetts
Board of Building Regulations and Standards ��nR
\,�,� ' _ Massachusetts Sta[e Building Code. 780 CMR. 7'h edition MUNI('IP:\LI'I'1'
USE
� Building Permit Application To Construct. Repair, Renovate Or Demolish a R�'�'�+'�'����������+�)'
One- or T�ro-Fnrrrrlv Dx�elfing l. ?rxi3
This Section For Official Use Only
Building Permit N ber. Date Applied: 3 3 �
SignuWre: "`,yf`� �'u'`^ '3/ .3/ fl g
BuilJing Commissiunrd Inspecior uf Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.1 Assessors Map & Parcel Numbers
�O '� �a\ 1=- � S w\e+� mn
l.lu Is this •rn arcep[ed street'?yes_ nu_ Map Number P:uccl Numtxrr
1.3 Zoning Informedon: 1.4 PropeKy Dimensions:
Zoning District ProposeJ Use Lot Are•r(sq ft) Fromage(ft)
1.5 Buflding Setbacks(ft)
Front Yard Side Yards Re;v Yard
ReyuireJ Provided Required Provided Required Pruvidcd
1.6 Water Supply: (M.G.L c.40. §54) 1.7 Flaod Zone Intormatlon: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal sys[em ❑ �
Public E� Private 0 Check if esO
SECTION 2: PROPERTY OWNERSHIP�
2o.1 �Owner�of Record: �v.�
Dot'LS �C l �S _ �� BQ.NL O.� �0.`wfR--� SL��p�T '-�-' 'y
Name(Print) � AJdress for Service:
� — GT�- �Iltl- 0 2cr�
Signature
� Telephone �
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction O Existing Building O Owner-Occupied O Repairs(s) ❑ Alreration(s) Additiun ❑
Demolition ❑ Accessory Bldg. ❑ Number uf Units_ Other ❑ SpeciFy:
Brief Description of Proposed Work2: R:3 �-.�-- £- t+ �F a�'�.��'^ ^' � 01� �'�
\yy�xlTCo.7 a.cCeSS �
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimared Costs: Of[lclal Use Only
[tem (Labor and Materials)
L Building $ $000 • o �• Building Permit Fee:$ [ndicate how f'ee is determined:
❑Standard City/fown Application Fee �i
2. Electrical $ O Total Project Cost�Qtem 6) x multiplier x
3. Plumbing S 3 Ood • o0 2. Other Fees: $
4. Mechanical (HVAC) $ —e-- Lisr.
5. Mechanical (Fire $ _$� Total All Fees: $
Su ression)
Check No. Check Amounr. Cash Amuunt
' 6. Total Project Cosh $ g d v� Q� ❑ paid in Full O Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
' S.1 Licensed Construcdon Supervisor(CSL)
CS 4l\33 �\-30 -.70��
��.�,� �� , po�. License Nwnber Expirution Datc
Namc of CSL- HolJer . t , • -•.
SSO St. Ou�t.,�e,,, �nrc ,_
List CSL Type(ser below) � 6
� 4ddn � T Descri tion
U Unresvicted(u w 3S,00p Cu. Ft.1
�' — R RestricfeJ 1&2 Fumil Dwcllin
I Signawre M Masun Onl
\ 4��'114'°2�8 Rc RcsiJcntial Ruotin Covcrin
��� Tclaphone WS Residential Window anJ SiJin�
� SF RcsiJcntial Solid Fuel Bumin A lianeo Installwiun
D Residential Drmulition
5.2 R�egtisYtered�H�Improvement Contractor(HIC) �ag3V�
HIC Cumpany Name or HIC Registr;mt Name Registration Number
sso r�o�rr,s �' dvsu c rn-c� 2p t1,1 3-30- 2oo'j
A ress
p� �tYl-lltl'0200 Expiratiun Date
Signa[ure Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDA VIT(M.G.L.c. 152. $ 25C(6))
Workers Compensation Insurance affidavit must be compkted and submitted with this application. Failure tu pruvide
this uffidavit will result in the denial of the Issunnce uf 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
�, , as Owner of the subject properry hereby
au[horize - to act on my behulf, in all matters
relative to work authorized by this building permit application.
Si namre of Owner Date
SECTION 76: OWNER� OR AUTHORIZED AGENT DECLARATION
I, '(a(]«-� �St- ,as Owner or Authorized Agent hereby declare
that the starements and information on the foregoing application are true and acwrate,to the best of my knowledge and
behal£
��� �
Print ame �
3 3 - 0�
Signawre of Owner or Au[horizcd Agent Date .
(Si ned under the ains and nalties of r'u ) ��
NOTES:
L An Owner who obtains a building permit to do his/her own work,or an uwner who hires an unregisrered cuntractor
(not registered in the Home Improvement Contracror(HIC) Program), will not have access ro the arbitration
program or guaranty fund under M.G.L.c. 142A. Other import•rnt information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Toeal floors area(Sq. Ft.) (including garage,finished brsemendattics,decks ur purchl
Gross living area(Sq. Ft.) Habitable rWm count
Number of iireplaces Number of bedrooms
Number of bathrooms Number of half/ba�hs
Type of heating system Number of derks/porches
Type of cooling system Enclused Open
3. '"fotal Project Square Footage"may be substitured far'"I'utal Praject CosP'