35 BOARDMAN ST - BPA-12-350 SIDING, INSULATION & TRIM \� — _.----- The COmmOnwealth Of Ma55aC'hn5etf5
( i Board Of 13uildin CITY OF
b Regulations and Standards
vvV Massachusetts State Building Code, 730 CMR SALLM
ti"•• Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised 1/m•_'ll l l
One- or Tun-Fatnd Dmelli)W
This Section For Offl Use Onl j
Building Permit Number: Da Applied: J -
lhiilJing OlTicial(Print N,unc) Signature
SECTION I:SITE INFORMATION
1.1 Property Address: 1.2 Assessor M1lap arcel Number
L la 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 ll) Frontage(Il)
1.5 Building Setbacks(R)
Front Yard Side Yards Rem.Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:( . I.c.40.§5a) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check fifes❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownerl of Record: / ,,
r/ E C-' /' [3/7 r w 5/,( i ✓/sneer\ 2!Za-so O! 9 7 6
N;line(Print) City,,State.ZIP
3 s3 J3fl�i
Nu.and Street Telephone &nail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building❑ O ❑ Re
Owner-Occupied pairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and \laterials) OfRcial Use Only
I. Building g I. on Permit Fee: T Indicate how fee is determined:
2. Electrical g ❑Standard City/Town Application fee
❑Total Project Cosh(Item 6)x multiplier
3. Plumbing $ ]. Other Fees: $ _
a. \loch:mical tit\':\C'1 T List:—_ --� �
5. Mechanical iFirc
Suppression) $ rotui :\IlFees: $_
f, Total Project Cost: $ IOt Ooa. a0 Check No. Check :\nwunt: _ C'nsh:\mount:
❑Paid in Full Cl Outstanding Bal:mce Due:
O� OCIh fry hl�(-
r
SECTION 5: CONSTRUcriON SERVICES
5.1 Cbnsction Supervisor License(C'SL) 0.20 ifS 6 _ - ___
License Number f cpiratuut Date
Nantc of l'SI. I lulder
Liit C'SI,1)pe(see below)__--.—_--
_� I'N pe Description
No. and Street
g� G U l4vesuiaeJ I Buildin n ti to i3,11110 at. Il.l
_ . _ h 9*7 9 7 R licstricted I r2 Funil l Dttcllin
C'i tvi Fottn.Slatc, 11 Ni Masonry
RC Rtwlin C'ovcrin
----- WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
I cic hone Fnwil address D Demolition
5.2 Register IloeImprovement/Contractor(HIC) Ioa /6'7 G /O `l
frmern,J,p-.y 4 :r- (/sit �..— 111C Registration NumNr Expiration Date
I M C'ompan) Name or 1IIC Registrant Name
1 G Email address
`L,r.,� �i✓�-
Nu. and Street
. `Jew Y l6--7Vs 5$J-2
City/Town.State,ZIP .rule hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.9 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 7u 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 Nwne(Electronic Signature) Dale
SECTION 7b: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.
j�AYManm F�ERvt'RC 9�'7G�ri
Print Owner's or Aulhurired,\gents Name Ililectronie Signaure) Date
NOTES:
I. :\n Owner who obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor
(not registered in the Hume Improvement Contractor(HIC) Program),will nr� have access to the arbitration
program or guaranty fund under.M.G.L. c. I J'_A.Other important information on the HIC Program can be liwnd at
ttw,t n,.n. g,tt .,,.i htfonnation on the Construction Supervisor License can be found at t%wt.nats z1o% Ip,_
2. \\'hen substantial work is planned, pro%i, the information below:
Total flour area Isy. ft.) _ (including garage, finished bascment attics,decks or porch)
Gross living:area lsq. 11.) _ Habitable room count _
\umber or fireplaces_-_- - ..._ Number of bedrooms
Numher of bathrooms -- Number of half b;ohs
I)pe or heating s)stem _ .- ... . _. _ Number of decks, porches
I\peol'caulings�stcm _ - Inclosed _ . . . --Open . .
). "htgal Project Square Footage-maN he substituted lift-1 ofal Project Cost"