0031 BOARDMAN ST - BPA-14-778 OR 751 ROOFING -Is 1 - I �S c-K s 3
The Commonwealth of N[assacliusetts RECEIV D
Board of Building Regulations and Standards INSPECTIONAL SER WF
Massachusetts State Building Code, 780 CNIR � M
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate 0r2WptWh4 A I: 5b
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number:`, Date;Apphed:>;
Building Official(print Name) "Si nature e
SECTION 1:SITEINFORtMATION
1.1 Pro erty Address: 1.2 Assessors Map& Parcel Numbers
==3 5F
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 fit) Frontage(ft)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Red Provided Required Provided Required Provided quire
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0' Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION2:; PROPERTY'OWNERSHIPr' ' `
2.�OOLrG%Alc6 A a)917S
Name(Print) City,State,ZIP
ai bdwmt d sq� _
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF,PROPOSED WORK''(check all that apply)
New Construction ❑ Existing Building qK1 Owner-Occupied ❑ Repairs(s) R1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑. Specify:
Brief Description of Proposed Work': A&fJCT G r < f. "4011YOA) L 06? a
AT 1Wv ,fVM !hoc Me banns tizEalO. n6/W 1�l, w su>E�nr�Mr _ in eta,
N4 � /dL N.#/A/ �iO6 4t14
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SECTION 4: ESTIMATED CONSTRUCTION COSTS
[ter Estimated Costs: Official Use Only.
Labor and Materials
1. Building S /Z GaO. oo I Building Permit Fee:,S Indicate how fee is determined:
❑ Standard.;City/Town Application Fee
2. Electrieal S ❑Total Project Cost',(Itemb)x multiplier x
3. Plumbing S 1 Other tees: $ �� x
d. Mechanical (IIV\C) S List (/
5. Mechanical (Fire
Su� ression) "Cola!All Fees .S_
Check No.__Check Annual: Cash Amount
6 l'otal Project Cost S �)�G / ❑ Paid in Full ❑ Outstanding Balance Due:____—_
------ I M Pa --/ - qT -l•O- 114 ---- --- ---- --- -
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SECTION 5: CONSTRUCTION SERVICES
5.1 C nstruction Suiervisor License(CSL)
License Number Expiratio Date
Namll of CSL iI[older. r , .t
/ , ` List CSL Type(see below)
�v
No and St� - Type Description
UUnrestricted Buildin s u2 to 35,000 cu. ft.)
T HY/, M4 D�9�6 R Restricted 1&2 Faintly Dwelling
wn State LIP Masonry Qt fo �I y ,
Roofing Covering
Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
felt hone Email address Demolition
5.2 Registered Home Improvement Contractor(HIC)
114-A)AU 49 A�Tc�Z.S HIC Registnttion Number E.rpun
IIIC Co an Name or I IC Registrant Name
/��p, AG y ter?
No.an Street Email address
via�f
- n4lnlg 97f�; -3/160
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 .......... P,-� 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 7h: OWNEW 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.
S/
4t���t's Name(Electronic Signature) Date
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 can be found at
�oww.m:us.eov oca Information on the Construction Supervisor License can be found at www.mass.,�o�/(IL
2. When substantial work is planned, provide the information below:
Total floor area(sq. It.). _(including garage, finished basement/attics, decks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplaces- Number of bedrooms - -
Number of bathrooms _ Number of half/baths _
Type orheating system -_------- - Number ot'decks/ porches --
I'ype of cooling system —.-- Enclosed_ Open _
-10ta1 Project Squ,uc Fuotuge" inay be subvtinitM tea I'w;ll Project Cost"