81 BOSTON ST - BPA-2010-822 ROOF II -
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a The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
m OF"LE! Massachusetts State Building Code, 780 CMR, 7 edition
Revised Jwnrury
Building Permit Application To Construct, Repair, Renovate Or Demolish a /. 2I108
One-or Two-FumilP Dwelling
This SLWion For Official Use Only
o Building Permit Number: Date Applied:
Signature:
Building Cummissio eri Inspector of Bull i Date
SECTIO 1:SITE INFORMATION
1.1 r_operty Address: 1.2 Assessors Map At Parcel Numbers
I.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 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Public❑ Private❑ — Municipal❑ On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownertof ecord•
a� % N
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building Is 1. Building Permit Fee:S Indicate how tee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List: -
5. Mechanical (Fire S
Su ression Total All Fees: S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S �' (� /�` ❑Paid in Full ❑Outstanding Balance Due:
{ y
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) IV 3 1��3
`a r �\` —` S - -Q._c�, License Number lirptratiun )ote
Name ul C'SL-Ilolder List CSL'type(see below)
4" 'f Description
Address q// Q U l Inrcstricted u to 35,000 Cu.Ft.
'yJ.� ✓.l--G'� R Restricmdlffi2Famil Dwelling
M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 iisterer�Home Improv�emeot Contractor(HIC) ` >� �--�
I IIC Company Name or IIIC Regi tram Nam Registration Number
Address / Expiration Date
Signature Wiz =_ 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...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 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.
Signature of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1 ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Sitined under the pains and penalties of 'u
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 ag have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I IO.RS,respectively.
? When substantial work is planned,provide the information below:
Total foors area(Sq. Ft.) (including garage, finished basemenUartics,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"may be substituted for"Total Project Cost"