19 BENTLEY ST - BPA-16-819 The Commonwealth of Massachusetts OF
Board of Building Regulations and Standards,w,f[; RY. EM
Cf Massachusetts State Building Code,780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate ZRtP9 oliP12a 11: 0 4
One-or Two-Family Dwelling
This S„„ectjonpor Offlo�l:Use
\ Building Permit Number: Date Appboclt
l3allclag „clef(Priot "e) afgnature
ITSECTION 1:8I1 $pTF'ORIVIATION
1.1 P ope Address: 1 Assessors Map&Parcel Numbers
Y771`la'
1. a Is this an accepted street?yes no Map Nmmber Parcel Nmmber
.
Information: Property Dimensions:
Zonm istrict Proposed Use Lot Area(sq it) Frontage(it)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
Water Supply: (M.G L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Pubb Private❑ Zone' — Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es❑
SITt:TiON2i PBOP15R71'$VVN$RS11TYt . _
2.1 erp of Record: �� 1 D .�O
q UIId �3 a4 o a
e(Print) . City,State,ZIP
/ S befll'%V 7ff-5W- r/ 22 PiG5alem��ma,'l,tt
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK;(check aIi that apply)
New Construction❑ Existing Building O Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Specify:
Brief Description of ProposedWorle: lIM SOY".¢. 5k4 lid M
�I6)7 r��inf 1 �Tnn(�a V
SECTION 4:ESTfA7ATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials
1.Building $ 1• Balli#ng Permit
$ Indicate homy fee is determine&
❑Standard city/rown Application Fee
2.Electrical $ (7 Total Project Cost?(item 6)x multiplier x
3.Plumbing $ 2. Other Fees; .S.
4.Mechanical (HVAC) $ List'
5.Mechanical (Fire $ Total AD Foes:$
ression
Check No. Check Amount Cash Amount'
7
6. 1 Project Cost: $ , ❑p pyrlt ❑Outstanding Balance Due:
r
McnoN 5 CCJmTR Cmiq SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
NameofCWHolderft ,IL. �,cY
- List CSL Type(see below)
No.and Street 'TYfe DesUption;
U Unrestricted to 35,000
R I Restricted 1&2F
City/rown,State,ZIP M I Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /Town State,ZTP Tel hone
SECTION&WORKERS"COMPEFPSA3Tt N I tIR"CE AFFIDAVIT(ALG-e.152.3
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...........❑
7a OWN$R AUTH RTZA Tb RE COIMI IXM WHEN
OWNER'S AGW QR C OR )FOR ING
1,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.
Print Owner's Name(Electronic Signature) Date
SECTION 9b:OWNEW OR AUTHORIZM AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
X
Print Owner's or Auth d Agent's Name(Electronic Signature) Dee
s. . .
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 can be found at
MM.mass.gov/oca Information on the Construction Supervisor License can be found at wwwma S` ov/d s
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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 Cosy' - '