11 BENTLEY ST - BPA-10-223 REPLACE 8 WINDOWS The Com momce:dth of MastiaChL]SettS
y Board of 131,111ding RC1ulati011S and Standards all NICIVA1.I'Il"
IxIaSSHChnSCtIS State BUildill, Code. 780 CNIR. 7"' edition I .tit'
Building Permit Application To Construct. Repair. Reno\ate Or Demolish a 'oos
Otter or Tiro-Fancily Duelling
1 /\ This Section For Official Use Only — - �
\lJ Building Permit Number: Date Applied:
Sig❑a WI'e; '� _.__
13uildinE Commissioner/ InspecW of 1 uddings Date
—_
SECTION 1: SITE INFORMATION
1.1, 1.2 Assessors :'Map & Parcel Numbers
------ I
Ma Numher Potreel Numhrr
I.lit Is this an accepted street? yes_ no_ p
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use
Lot Area(sy I't) Frontage oil
1.5 Building Setbacks(f )
Front Yard Side Yards Rear Yard
I Required Provided Required Provided Required Pru Hded
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❑
SECTION2: PROPERTY OWNERSHIP'
Ow 7gt of Record
NmneiPrinn , Address forSeerrvicce:: 1W —•�
/1� 0 �1Gt=_�_�?__llAAA1� ) � 7�G2 ►.n' 1 Day _
e p
�Signaturc Telr hone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction ❑ ExistMorkg
Owner-Occupied ❑ Repairsts) ❑ Alteration(s Addition ❑
Demolition ❑ AcceNumber of Units_ Other ❑ Speedy:
Brief Description of Propose
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
*13lumbing
(Labor and Materials)
$ L Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
$ ❑Total Project Costa (Item 6) x multiplier x _
i
$ 2. Other Fees: $. HVAC) $ _ List
i. Mechanical (Fire 1
"furtl :all Fees: $
Su, resswrt)
Check NO, Check :\mount ('.uh :\mount_. .__
6 Total Project CosU $ 3 ❑ Paid in Full ❑ Outscutding Balance Uua__.__
SECTION 5: CONSTRUCTION SERVICES
5,1 Licensed Construction Supervisor (CSL) -7-z �.��aDl I
i =f—
I
n.c Numher Ifxpir:wan ).ue
NanuofC'SL Holder
CSl_I'cpe;see helnw)c Deschvum
1` o, flll'C,Irleled(U)fU 3i,(IUU t'll. I'1.i
Restricted I,@'_ Fanul� D%kclline
SWIlatur 1 %1 \la,onn Oniv
!-� RC ResiJonual Kaoline C,nerim1
Telephone %%S Rc,,&Tival \Vnidu�� .mJ S...nu _.
SF ReeiJtniial Sohd Purl Bunune 1 l Iliuucr In.�alLui�m
D lic,idenual Dcmnlunm
5.T Regi'tered Ilume Improvement Contractor (IIIC) 1 Q'toa9
sty Se V
HIC Company Nano ur IC R Tstrant Nan1C� RC gl al rallull Number
� a l
Addre s
Expiration Yale
Signature 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. F dare 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, .[ I u a L2 Y e C,ra C - as Owner of the subject property hereby
authorize Chn f7h r 7b(-ZU to act on my behalf, in all matters
relative to work authorized by this building permit application.
L
Signature of Owner Date
SECTION 7b: OWN,EW OR AUTHORIZED AGENT DECLARATION
I, C-hrl5+20 LV r ZDf-7_ ,as Owner or Authorized Agent h7de�laiethat the statements and information on the foregoing application are true and accurate, to the besrof my
behalf.
Print N
.Signature of Owner or A thorizeJ•4gent Date _
(Signed under the .sins and enalties of er'ur ) I -
NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered auuranor
(nut registered in the Home Improvement Contractor(HIC) Program), will not have :recess to.the arbitration
program or guaranty fund under M.G.L. c. 112A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.R6 and I I0.R5. respectively.
_'. When substantial work is planned, provide the information below:
Total flours area lSq. Ft.) Iincluding garage, finished husement/attics, decks or lir -
Gross.living area iSq. Ft.) Habitable room count _
Number of fireplaces Number of hedrnnrn, -- --
Number of h;uhrooms Number of halt/h:uhs
fvpe of heating systern Number of decks/ p ,ichcs __----_---_
Type of coolinL s}lstem 1'_ncln,ed - Open._.__—
3. "Tuull Project Square Fuutage" may he substinaed fin"Tnial Project Coal"
J