8 BOSTON ST - B-12-153 REPLACE FRONT DOOR, VINYL SIDDE I,
J� The Commonwealth of Massachusetts
OF
rrk, Board of Building Regulations and Standards SIALEM �V
@� TY
Massachusetts State Building Code, 780 CMR i
Revised Mar 2011
Building Permit Application To Construct, Repair,Renovate Or Demolish a `p
One- or Two-Family Dwelling
This Section For Official Use O y
r Building Pei mltNumber; Date Ap p I i e 1!!"
S
Building Official(Print Name) Signature Date C
SECTION I: SITE INFORMATION
1.1 Property Address: ft/� 1.2 Assessors Map& Parcel Numbers '
� (305�o�J S'�
I.lit 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 Il) Frontage(Fu
t
1.5 Building Setbacks(ft) I
Front Yard Side Yards lZear Yard
Rsyuired Provided Required Provided lZequired Provided
n
L(,Water Supply: (M.G.I.Q.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: ;
Lone: _ Outside Flood Zone?
Public ElPrivate❑ Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Rercc�ord:: L �
—�E4.E& 4SA6p S'flI�.0.0 ,1� Or9. �e)
Name(Print) City;State,ZIP
.� I�os1ov s4
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK''(check all that apply) !
New Construction ❑ Existing Building 2L Owner-Occupied ®- I Repairs(s) [S. I Alteration(s) ❑ Addition ❑
i
Demolition ❑ Accessory Bldg. ❑ Number of Uni[s� Other ❑ Specify: ��
Brief Description of Proposed Work:
' s1 IAC.9 -9notJ - 00ti I„�V
SECTION 4: ESTIMATED CONSTRUCTION COSTS I`fir
Estimated Costs:
em Official Use Only ri
(Labor and Materials) ''II
I. Building $ /S" p00 ,oo I. Building Permit Fee: $ Indicate how fee is determined: ,f
❑Standard City/Town Application Fee I'
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x !.
. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
i
Total All Fees: $
Suppression)
Check No. Check Amount: Cash Amount: +�
6. Total Project Cost: $ /,j 0 00 , 00 ❑ Paid in Full ❑Outstanding Balance Due:
aI6 /CPO
I
SECTION 5: CONSTRUCTION SERVICES j
5.1 Construction Supervisor License(CSL)
�( 1 f + A K475 r2-as- ao � � I
T N
k O -1 V%S C oo -Y�t� VLY License Number Expiration Date
Name of CSL Holder
(( List CSL Type(see below) 0/ 2l U300b 1Atooil S�_ I
No.and Sheet "type Description
O 1, U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/fo ,Slate.ZIP M Masonry
RC Roofing Covering
INS Window and Siding
SF Solid Fuel Burning Appliances
33Y yq0 o4Q g, I Insulation
"telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) j
-Th.o I'L„ s Cod-t,,,b €I1,J
HIC Registration Number Expiration Date
HIC Company Name or FF/t IC Regist at rant N e i
!7 t to00 O1f1W h.J ✓��
No.and Street Email address
1� of a 339yyoe ��.2
Cit� Town, State,Z IP Telephone I
SECTION G: 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 ..........M No ........_. ❑ �f
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 'T 1t D'�-t A S C.0' _h, b B it.
to act on my behalf, in all matters relative to work authorized by this building permit application.
i
Print Owner's Name(Electronic Signature) Date (gyp
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION,
i
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. "t
(Q —
tY_Qaft it
Print Owncr's or Authorized Agent'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 I
program or guaranty'fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.aov/dps
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 1
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 Cosy'
i