0015 SUMMIT AVENUE - BERTRAM TERRACE BPA-14-1486 GlC lZc�o 3 3 -3
The Commonwealth ofMassacch Massachusetts nNAL SERVIC
Board of Building Regulations an 5 SAKI EM
Q Massachusetts State Building Code, 780 CMR
�cCC ((�� A 1, 30,R evisedMar2011
Building Permit Application To Construct,Repair, RvalePO�ISemolish a
3 One-or Two-Family Dwelling
This Section For Offpial,Use Only
Building Permit Number: D e Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map At Parcel Numbers
1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: I S lS v mull•( Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Requtred Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
St C tos^— n\Gl0
Name S ^
No.and Street Telephone �' Email Address
SECTION 3:DESCRIPTION OF PROPOSED WO RK2(che k all that apply)
New Construction❑ TExisting Building❑ Owner-Occupied ❑ Repairs(s) t I Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units I Other ❑ Specify:
-Brief Description of Proposed WorV: SfSJ�I\ Lc-\\v\05t.._ Qv-, 41
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
l.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: j
5.Mechanical (Fire $
Suppression) Total All Fees: $
_ Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 1S b ❑Paid in Full ❑Outstanding Balance Due:
5(;E:NT- -CD co�z• °C �► �
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) `����-�
,c ah t pl g-�!- �c)l Y i to License Number Expiration Date
Name of CSL Holder t
List CSL Type(see below) \�
N` Stre �wU�, �� a Description
,.tF C, U Unrestricted(Buildings u to 35,000 cu.ft.
Non )Crty� State,ZI - _`\ R Restricted 1&2 FamilyDwelling
M Masonry
�1 RC Roofing Covering
WS Window and Siding
v SF Solid Fuel Burning Appliances
1Q-GQ11 -c�\.�j' I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
Registmt,2 Number Expiration Date
HIC Company r4 afric or HIC Registrant Name
01 C-",t'l , 'Asi,e
No.and Street Email address
City/Town,Statb,ZIP — 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 ..........iT No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR• 1 P
�� APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize 0) _11v3
to act on Iny behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic SignaturereT Date
SECTION 7b:OWNEW OR AUTHORIZED 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.
P to u's or Authorized Agent's Name(Electronic Signature) �^ ^,hate
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 can be found at
ma w.mass. og v/oca Information on the Construction Supervisor License can be found at LA .mass. ovg /dns
2. When substantial work is planned,provide the information below:
Total floor 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 halfibaths
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'