1 BOARDMAN ST UNIT 2 - BPA-16-69 WINDOWS 2S- RECEIVE
The Commonwealth of Massachusetts ERVI
CITY
Board of Building Regulations and Standards 1016 JAN 2 ^ S(�LEM
/ Massachusetts State Building Code, 780 CMR Rt?l'�'sV i&33oll
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Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
building Permit Number: DateAp ed:
„ , 5
9 building OlTiciul(Print Name) Signature
SECTION 1: TE INFORrMATION
V LI Pr perty Address: it 1. tssessors blap& Parcel Numbers
�C—�(
1.la Is this an accepted street?yes_ no Map Number Parcel Number
Coning Information: 1. roperty Dimensions:
Zoning District Proposed Use Lot Arca(sq tt) Frontage(It)
1. Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided. Required Provided
JPLlibliC103e
r Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.9 Sewage Disposal System:
Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es❑SECTIONZ: PROPERTY OWNERSHIP!`
ertof Record: t3M C71g70
/t) City,Slate,ZIP
n/R._fil✓J'r,9CAL, Lw,-
No.
, -Nu.and Street
Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Ekisting Building❑ Owner-Occupied ❑ 1 Rein] s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ 1 Number of Units_ I Other Cl Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 0Mcial Use Only
Labor and Materials)
I. building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical 5 ❑Total Project Cosh(item(i)s multiplier s
3. Plumbing S 2`,'A Qther Fees: S
4.Mechanical (FIVAC) S List: ( o ���
5. Mechanical (Fire Total All Fees:3
Suppression)
m Check No. Check Amount Cash Amount:
6. rtal Project Czrst .i / Q 0 ❑Paid in Full ❑Outstanding Balance Due:
Vh f\4 L-Ac-5� <%Ic, VA - (:15.
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor.rtL}cense(CSL)
:t3 � tt�L
License Number ExpimtionDate
-
Name of CSL Holder list CSL'rype(see below)
Type Description
No. and Street
U Unrestricted(Buildings tip-to 35,000 cu. Il.
R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP M Masonry
RC fing Covering
WS 1Vindow and Siding
SF Solid Fuel Burning Appliances
I I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Dane
I IIC Company Name or HIC Registrant Name
No.and Street Email address
Cit /Town,State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.ISL§ 2SC(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 Isimance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No........... 0
SECTION 7a:OWNER AUTHORIZATION TO BE COh1PLETED WHEN'
OWNER'S AGENT OR CONTRA&MOYPLIES,FOR BUILDING.PEMHT
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) - Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
Dy ntcring my name below, 1 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.
1 /Zf,
Print caner' uthorizcd A cnt's Name Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
registered in the Home Improvement Contractor(IIIc) Program);will not have access to the arbitration
program or guaranty fund under M.G.L.-C. 141A.-Other important information on the HIC Program can be Coon at
www.mass.cov'oca Information on the Construction Supervisor License can be round at ww�:'dus
2. When substantial work is planned,provide the information below:
Total floor area(sq. R.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. tt.) Habitable room coma
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
'rypeorcoolingsystem EnclosedOpen
J. `Total Project Square Footage"may be substituted 1or-rotal Project Cost"