7 BOARDMAN ST - BPA-14-1214 KITCHEN & BATH REMODEL a� The Commonwealth of Massachusetts
s� Board of Building Regulations and StandardsREOEIVEO CITY OF
Massachusetts State Building Code, jk% ZONAL SERVICES SALf;M
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demtlj�;h 3
Otte-or Tivo-L"amily Dwelling 1% jUL 11
"This Sec[ion For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Signature Dale
SECTION I:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
-7 pee n m
1.la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zonina Information: 1.4 Property Dimensions:
%Doing District Proposed Use Lot Area(sq 11) Frontage(it)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (ibLG.L,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Lone: — Outside Flood Lone?
Check if yes❑ Municipal O On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
s1 P -��}e S _ 301em , MA _ 970
Name(I'min City,State,L,II'
7 Ece-r rl- -_ 91 n? 71GN ri l; rkcra o
No.and Street Telephone .mai Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building&I Owner-Occupied Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work': �'ir1 e ,('i� � -
gab
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estinmted Costs: Official Use Only
(Labor and Materials) y
1. Building $ ! jg Voo 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical ❑Standard City/Town Application Fee
'Zoo ❑Total Project Costr(Item 6)x multiplier x
3. Plumbing $ (p SOO 2. Other Fees: $
4. Mechanical (IIVAC) $ I t j DD List: 3uld
5. Mechanical (Fire $ ) ��
Su ressiom) Total All Fees: $_
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 3 t Lu0 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Fxpiration Date
Name of CSL Bolder
List CSL'I'ype(see below)
r r •1 C.- r .
No.and Street 'L I•yj Type Description
U Unrestricted(Buildings up to 35,000 cu. It.
R Restricted 1&2 Family Dwelling
-
Citylfown,State,ZIP M Mason
ry
RC fooling Covering
WS Windowand Siding
SF Solid Fuel Burning Appliances
1 Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(IIIC)
IiIC Registration Number Espirrtion Date
hIIC Company Name or FIIC Registrant Name
No.and Street
Email address
City/Town,State,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 .......... ❑ No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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 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.
Print Owner's or Authorized Agent's Name(Fdectronic Signature) pate
NOTES:
I. 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
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.ntass.eov/dns
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. R.)_ Habitable room count
Number of fireplaces-__ Number of bedrooms _
Number ofbathrooms __ NumberofhaWbath.s _
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"
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