27 BOSTON ST - BPA-16-25 ROOF 'rhe Commonwealth or Massachusetts CITY OF
W
Board of Building Regulations and Stagdoq� RECEIVED ITY O Massachusetts State Building Code, 780f CTiONAL SER ig
ed,Nar 201
Building Permit Application To Construct, Repair, Reno Q Or em lish a
One-or Tivo-Fnmily Dwelling I �i ' A 5 O
This Section For official Use Only
Building Permit Number., Date App
1 Building Otrrciai(Print Name). - Srgnattrre
SECTION 1 SITE INFORh1ATION.'
( I.I Pro rty Address: 11 Assessors rNap di Parcel Numbers
I.is Is this an accepted street? es no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dlenensloas:
Zoning 015"ict Proposed Use Lot-Arco(sit 4) Frontage(it)
1.5 Building Setbacks(Rj
Front Yard, Side Yards Rear Yard'
liequimd Provided B Provided Requ
eguiled ired' ' Provided
1.61Vater Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal$ysleot:
Zone: Outside Flood Zone?
Public O Private O -. Mucipal O On site disposal system 13
Cbedc if " O. :.. ni
SECTION I::PROPE�l7 Y.O�VNER$HIP4
2.1 O err of Record I2M �
IN)me(Print) .. City,suite,ZIP
No.and Stmet Telephone Email Address
SECTION.3:DESCRIPTION OF PROPOSED WORKS(check all tbat apply)`
New Construction O E fisting Building O Owner:Occupied O Repairs(s) O Alteration(s) 0 Addition O
Demolition O Accessory Bldg.0 . Number of Units. Other O Specil):
Brief Description of Proposed work=: S i
SECTION 4.ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OfRclal Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee:S Indicate how re.e is determined:
2. Electrical S - O Standard Cilyfrown Application Fee
Total Project Costi(Item 6)x multiplier x
3. Plumbing $ 2?$Xher Fees: S
a.Mccltanical (HVAC) S List:
5.Mcchanical (Fire S
Suppression) Total All Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S /O 106, 0 0 Paid in Full ❑Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Sulpery b}Lle a e(CSL) �/ c2 3 1
n C/ovnr License Number Expiration Date
Name of CSL Holder /A Q Y List CSL'fype(see below)
9 dh Type, Description .. .
No.and Street
U Unrestricted Duildin u to 35,000 cu. 11.
R Restricted I&2 Famii Dwellin
Cityfruwn,State,ZIPS M Masonry
Roo I'm Coveri
Window and Siding
SF Solid Fuel Burning Appliances
7Sl/ ?�/5�C1 Slot 1 I Insulation
Telephone Emoil address D I Demolition
5.2 Registered tome Improvement Contractor(HIC) 160611 `7
0,f)j HIC Registration Number Expiration Date
In ompgn HIC
No.
No.and Street yoga Email address
140'ier1. ILZ3!a —
CitvJTown.State.ZIP Tele one
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVI E(M:G,L.c:132.g 2$C(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 Is§uance of the building permit.
Signed Affidavit Attached? Yes..........a No...........O
SECTION UtOWNERAUTHORIZATIONTOBE.COMPLETED,WHEN' :,"}
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING.PERh11T'
1,as Owner of the subject property,hereby authorize n� nilem r?n5 -
tj act
toon�my behalf,in all matters relative to work authorized by this building permit application.
/ be� f,
'�'+ SY Date
Print Owner's Name(Electronic Signature)
SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my name below,)hereby attest under the pains and penalties of perjury that all of the information
contained in this M/, placation is true and accurate to the best of my knowledge and understanding.
Print 0%v is 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
knot registered in the Home Improvement Contractor(HIC)Program);will LWI have access to the arbitration
program or guaranty fund under M.G.L.c. Id2A.Ot ortanf in t—ion on the HIC-Prog—rrm can be ro`u�r d at
Other
www.mass.eov,'oca Information on the Construction Supervisor License can be Found at wvuw.masssov/dns .
2. When substantial work is planned,provide the information below:
'rotal floor area(sq. R.) N .(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
'rype of heating system Number of decks/porches
'rype of cooling system Enclosed Open
J. "Total Project Square Footage"may be substituted 1'ur"Total Project Cost"