15 BOARDMAN ST - BPA-2009-137 DECK �9
The C'onmwnwealth of Massachusetts
('� Board of Budding Regulations and Standards FUR
V \IINI('ll'.\I.I'll
t � � Massachusetts State Building ('ode. 7311 CMR, 7"' edition
Building Permit Application To Construct, Repair, Renovate Or Demolish a Krri crJ.huuran t I
Once- or Tnvr-Fumity Do elling 1. _nns
This Section For Official Use Only
Date Applied: (1 —
BuiWing Permit Nun er: PP
Sienalure: -------
BuiqA.K.Eunissonei/ Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Ad rt'" 1 1.2 Assessors Map & Parcel Numbers
JS '904>dM n el —.--
hl Numher P:ucel Numher
I.la is this an accepted street'.r yes es no a__ _ P
1.3 Zoning Information: 1.4 Property Dimensions: I
%umng District --- Proposed Use Lot Are. (sq n) Fruitage (it)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
i
Required Provided Required Provided Required Prosi.leJ
1.6 Water Supply: (M.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone''
Public❑ Priv.-le ❑ Check if yes❑ Muni.:i il ❑ On site Jis x)sal s stem ❑
p' l }
SECTION 2: PROPERTY OWNERSHIP[
r2.I Owner of Rvord:
Name(Print) Address for Service:
y
jSignature 7 P
/Y Telephone F
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
N�j+/�rC /i4sr(t�e1i Existing Building ❑ Owner-Occupied Jy I Repairs(s) ❑ A Iteration(s)XI. Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units /21 1 Other ❑ Specity:
Brief Description of Proposed Work': �^ _ p i.%f'4 L --
_— S 4;—c ce o f A x _s�r /r /�1 n t l E ti Ji C. f Je 4
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials) I
1. Building $ /� as S�pp 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ O Total Project Cost' (Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (FIVAC) .$ List:
5. Mechanical (Fire $
Suppression) Total All Fees:
Check No./11'75 Check, Amount: �CP('ash :\mount__ j
b. Total Project Cost: $ (2. 7.11/' ❑ Paid in Full ❑ Outstanding Balance
p7
( 1
:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) CS y aj a? 21 e't$ 010��
License Number Fxpir:lion Dale
Namc o1 CSL- Mulder
�. Q, Ion
List C'SL'I\pc(see bclowl Ur. _ I
"f Dcseri soon i
\ddryy „ !�
i yi l linrestnctcd tit lu li.(N)U Cu. FL 1
Restricted 1&2 Famil Dttclline
Slenauue N Masonry Only
RC Residential Ruoline Cotcrin_
'telephone _ 11'S Rrsidrmial \Viola-rc .Ind Shin_ —
SF Residential Solid Fuel Burmne A t th:mce Ina.,ll.lw�u f
D Re,identiai Demolition
5.2 Registered Home Improvement Contractor (VIC)
HIC Company Name or HIC negistrmtt Name Registration Number —_
Address -- --
Expiration Date
',:eiehone
tit, nature 1
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. e. 152. § 25C(6))
Workers Compensation InStlrtt:lCe affidavit musi be completed and submitted with this application. Failure to provide
tors affidavit will result in the denial of the lssuance of the building permit. j
Signed Affidavit Attached? Yes .......... 6Q No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE: CONI PLE:TED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, Su.Scn S' Nh-5k), as Owner of the subject property hereby
l authorize fi ! .4 /t'r /140 /u to act on my behalf, in all nmtters
relative to work authorized by this building permit application.
j SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
- =50� STf(ryn54 , as Owner or Authorized Agent hereby declare
rh:u me statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf. t /�
_ Ju.14 n 54tF4 n SK l t — i
W �7 ,�.-(�
Signature of Owner or Auth ized Agent Date ley
(Signed under the 2ains and penalties of perjury)
NOTES:
I. An Owner who obtains a building permit to do his/her own work, or an owner who hires an umeeistered rontruaur
(nut 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 and
Construction Supervisor Licensing (CSL) can be found in 730 CMR Regulations 110.116 and 1 10.R5, respectively.
When .substantial work is planned, provide the information below:
Total flours area(Sq. Ft.) (including garage. finished base mentlattics, decks or porch)
Gross living area (Sq. Ft.) Habitable room count _
Number of fireplaces _ Number of bedrooms _
Number of bathrooms _ Number of half/baths
rope of healing system Number of decks/ porches -- —.
'type of cooling system_ — Lnclosed Open — --,-
3. "Total Project Square Footage" maybe substituted for "rord Project Cost"
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