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29 BOARDMAN ST - BPA-16-582 2ND FL DECK . cK I oc S The Commonwealth of Massachusetts RECEIVE Board of Building Regulations and Standards}ySPECT{WAL ly(=0R Massachusetts State Building Code,780 CMR trvtCIPALITY / USE Building Permit Application To Construct,Repair,Renovate 0M"sJ13 UJQsA15f,,2011 One- or Two-Family Dwelling LA This Section For Official Use Only I Building Permit Number: Date Applied: ^ Building Official(Print Name) Signature Date r J SECTION 1: SITE;INFORMATION 1 1.1 Properly Addre 1.2 Assessors Map.& Parcel Numbers 2 y' r ss•�marl Pr �a/erK Lla 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(R) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (f%4.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? p,,� Public Private❑ Check if yes❑R Municipal On site disposal system .0 SECTION 2: PROPERTY OWNERSHIP' _ 2.1= er'Jl cort I VIS .. Name(Print) (� City,State,ZIP R PWY M ` Cl? psi C qa3 No.and Str et Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply) New Construction❑ Existing BuildinglK Owner-Occupied ❑ 1 Repairs(s) 4K Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work : © 4 i r- L-XtsS� e/ Ge, et SECTION 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 Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (I VAC) $ List: 5. Mechanical (Fire - $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 1 95� ❑Paid in Full ❑Outstanding Balance Due: g�� SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) ct,IJ cv � License Number Expiration Date Name of CSL Holder List CSL Type(see below) lea No.and Street Type Description tl Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/Town, State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Numb��{{{ Expiration Date HIC Company Name or HIC Registrant Name �//j� `-p No.and Street 7 VEmail 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 �. I,as Owner of the subject property,hereby authorize to act on mybehalf,in all matters relative to work authorized by this building permit application. 1 <°+��yC se (4,1 S 1,5A Print Owner's Name(Electronic Signature) 13 to 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. 142A. Other important information on the HIC Program can be found at Information on the Construction Supervisor License can be found at 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"maybe substituted for"Total Project Cost"