10 BOARDMAN ST - BPA-2010-903 REPLACE 5 WINDOWS The Commonwealth of Massachusetts
s� Board of Building Regulations and Standards TOS
ki7 Massachusetts State Building Code, 780 CMR, 7ih edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a *W Ow 1a '
One- or Two-Family Dmrelling ANN&
This Section For Official Use Only
MBuilding Permit N r: Date Applied:
Signature: 61W /10
But in, orrimm,oner/Inspector°f Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property A s�s (/�yy� 1.2 Assessors Map& Parcel Numbers
I.I a Is this an accepted street'?yes_ noMap Number Parcel Number.
_
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ll) - Frontage(fl)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M,O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal 13 On site disposal system 13Public❑ Private❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
g2 BQ,
Name(Print) Address
Signature Telephone �C.�•�+
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units�- Other ❑ Specify:
Brief Description of Proposed Work':
14
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building $ I. Building Permit Fee: $ ligate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Total All Fees: S
Su ression
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ — 0 Paid in Full 0 Outstanding Balance Due:
,
SECTION 5: CONSTRUCTION SERVICES
5.1 License ConstructionSupervisor S
l tom-- ;RR,,,,,r,',td
7,
-i�� – '
., Num Ex i au n ate
Name u - Ider _ e( ee below)JRJ 2, 14
!A '
Addre Descri tion -
restricted u to 35,000 Cu. Ft.)
I&2 FarmlZ Dwelling
M IMason Onl
RC Residential Roofin Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Registered Hom rove t nt Co [or(HI )
HIC o y ame or H egistr t me Registration NumJbf�r
Addre s 1).
P..l�' �,�/�3 Expiration a e
Telephon^—a
ECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be c9mpleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuan of the building permit.
Signed Affidavit Attached? Yes ..........e 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.
2 [�
Signature of Owner Date
SECTION 7b�OWNERt OR AUTHORIZED AGENT DEC ARATION
1, 1 (moi lave— ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
,
Print Name
Signatu O ter or A horized Agent Date
Si ned under a ains andpenalties ofperjury)
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. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I 10.115, respectively.
2. When substantial work is planned, provide the information below:
Total floors 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 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 Cost"