23 BOARDMAN ST - BPA-15-623 ROOF e
&I The Commonwealth of Massachusetts RECEIVTaACP
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Board of Building Regulations and Stand*,dSPEC T IOhALC EM
Massachusetts State Building Code, 780 CMR vised Mar 2011
Building Permit Application To Construct,Repair,RenovaiMP 13�}nh3 1
One-or Two-Family Dwelling
M This Section For Official Use Only
Building Permit Number: Date Applied:
I Building Official(Print Maine) Signature _ Date
SECTION 1:SITE INFORMATION
1.1 Prop erty Address: 1.2 Assessors Map&Parcel Numbers
23 L'aP"Puw sT
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(it)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required 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? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2 PROPERTY OWNERSHIP'
2.1 Owner',of Record:
Ia.�' •AA WA-fry of qs/. .s444 "A O/97Q
Name(Print)i City,State,Z
a3.&M4MAWxi s fib'Sys GLS'/o
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check a
^ll that apply) '
New Construction❑ Existing Building�[ Owner-Occupied ❑ Repairs(s) RL Alteration(s) ❑ Addition El
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
B fief Description of Proposed Work: 70 Ti we, VA7I ML a�s oe/ mU,a fz*COMA SILC�/�n�
rr . APPW IM .,oJsD .St/iftd — i0 ALE 6/asNiub9
SECTIOV 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost3.(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:-
6.Total Project Cost: $ / r ❑Paid in Full ❑Outstanding Balance Due:
�lL\t��—p to�ZS
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)tr
6IJ MAa4WZ4t License Number Exp' ati Date
Name of CSL Holder
List CSL Type(see below)
3 �Af fNE La��
No.and Street Type Description.
PCAy,rtls O(q(pa U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP M Masonry
C Roofing Covering
WS Window and Siding
{ SF Solid Fuel Burning Appliances
CMQ�•J'J�-�(� I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) tJ 6
�I�tlk b►�C L°I (OK/f, TaR S HIC Registration Number E raf n Date
HIC Company Name or HIC Re strant Name
No. d Street Email address
City/Town,Stat ,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 ..........�k No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,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 7bt OWNER' 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.
Pnnt Owner's or Authorized Agent's Name(Electronic Signature) D to
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
3nnv:mass.>;ov..'oca Information on the Construction Supervisor License can be found at w�nv.mass.gov/dam
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 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"