23 BOARDMAN ST - BPA-15-288 CHIMNEY REPAIR Z Z 2Z0
The Commonwealth of Massachusetts
9 RE EIV rvI
Board of Building Regulations and Standards Nl
Massachusetts State Building Cade, 780 CMR INSPECTIO & rr)Ga
l -
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling 2015 APR 15 A
�^ This Section For Official Use Only
lJ Building Permit Number: Date Applied:
N Building Official(Print Name) Signature ' Date
(j SECTION I:SITE INFORMATION'
u + 1.1 Pro erty Address: S 1.2 Assessors Nnp&Parcel Numbers
(((� 1.1 a Is this an accepted street?yes t o Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
"Coning District Proposed Use Lot Area(sy tt) Frontage(It)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Reyuired Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.d0,§Sy) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal CI On site disposal system ❑
Public❑ Private❑ Check if es❑ P
SECTION 2: PROPERTVOIVNERSHIP'`
2 I Qwnert of Recor(�
V) SCrl C YER/LR�r�� J �t
NN me(Print) City,State,ZIP
'nom Mi4r! 5r
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Cl 1 Altemtion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work-:fz
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard Cityrown Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S P Qther Fees: $
d.NNcl tnical (tIVAC) S List:
5. Mechanical (Fire ) Total All Fees:S
Suppression)
Check Na._Check Amount: Cash Amount:_
G.Total Project Cost: S �t9O 6 ❑Paid in Full ❑Outstanding Balance Due:
��A1 I,EYJ q �Z\
SECTION 5: CONSTRUCTION SERVICES
' I Construction Supervisor License(CSL)
GS 0 t� F��� �. 4 IF License umber s ration to
Name orCSL Holder
// � I List CSL Type(see below) _
5— 4 n_5S ;J�`- UTV Q Tye. Description .
No. ;aJ Street nn
3 U Unrestricted 2Runi Lip-toing cu. It.
R Restricted )&2F:uni1 Dvvellin
Cityfruwn,State,ZIP M Maso
RC Roolin Covering
WS SViadowand Siding
qtre �/ SF Solid Fuel Doming Appliances
YN7/ C&Pi t ,44�-, `v¢.'T __ 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
NIC Registration Number Expiation Dade
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State ZIP Tel e hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L:c.152.§25.C(6)).
Workers Compensation Insurance affidavit must be co feted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Istuanc 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
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 Nane(Electronic Signature) Date
SECTION 7b: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.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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. 1 J2A.Other important information on the HIC Program can be found at
wvww.mass.cov'oan Information on the Construction Supervisor License can be found at www.nxiss."Ov,'Jus _
2. When substantial work is planned,provide the information below:
'rota) 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 of bathrooms Number of half/baths
rype of heating system Number of decks/porches
rype ofcolingsystem Enclosed Open
i. "I'otnl Project Square Footage"may be substituted for"'rutal Project Cost"