114 BOSTON ST - BPA-15-1002 SIDING/FRAMING cK ct 91 ( zzo
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The Commonwealth ofhlassaehusetts SEi )
ECT(� �� CITY OF
Board of Building Regulations and Stantawss S��LEM
Massachusetts State Building Code 780 CMR � P v�rr,y Mar 2011
Building Permit Application To Construct, Repair, RenoVdA1bA9pnolis�h a
t One-ar 71vo-Fnmtly Dwelling
This Section For Otreial Use Oni
BuildingPerrriltNumber. - Date.Applied.
J Building onicied(PHnt Nume). - Slgnutpra" �u1e
SECTION 1,SITE INFORMATION. +
1.1 Property AJdress: 1.E Assessors Map d's Parcel Numbers
I.I a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: ►.d Property Dimensions:
Zoning District Proposed Use Lut Area(sq it) Frontage(Il)
1,3 Building Setbacks((I)
Front Yard Side Yards Rear Yard
Required provided Requlrad Provided Required Provided
1.6 Wnter Supply:(M.O.L c.do,§SJ) 1.7 Flood Zore Informationt 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: — Outside Flood Zone? Municipal 0 On site disposal system O
Check If es0
SECTION2: PROPER'fYOWNERSRIP4
2.4 Owner'of Record: / �n„� � d 61V&')U U�
pme(prlm City,State,ZIP
golf 457-�
4Sfol✓ Sl aaa
o mid 'M Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check ill that opply)-
New Construction 0 Existing Building)q Owner-Occupied j>L Repairs(s) jk Alteration(s) 0 Addition 0
Demolition ❑ AccessoryBldg.O Number ofUnite�` Other 0 Speedy:
s'-'^f Descrlutlon of pronnsed tv .v-. �� S%/i we R oa ed '/c-97r-e M r
� '6Yea od -tea ocr '� �.9� wr ? �.ro�T o Nnrs2
SECTION Jr FSTIb1ATED CONSTRUCTION COSTS .
roans Estimated Costs: OBiefal Use Only
Labor and NL•derluls
1. Building S el(Sd , L Building Permit Fee:S Indicate how rev is determined:
0 Standard Cily/Tgwlk Application Fee
2.Eledricnl S 0 Total Project Cost!(item 6)x multiplier x
).Pluinbing 3 P ether Face: E
d,'Wehmtical (FIVAC) S - List:
S.Mechnnical (Fire S Total All Fees:S
Suppression)
�O O (,heck No._Check.\mount: Cash Amnunt:�
6.'fnlal Project Cust: 0 Paid In Full 0 Outstanding Dabroce Due:
Snrr--rb p,- z a.[o 3
T /Z 'SOHd 90:60 STOZ' LT -das
SECTION 5: CONSTRUCTION SERVICES
' 5.1 Construction Supervisor License(CSL) op
�L >�7(��F� �7 U License Number atin ate
Name of CSL Holder
List CSL Type(see below)
No.and Street 7 -T j Description
2r/ �h� /l �� U Unrestricted uildin s u to 35,000 cu.R
ity CL R Restricted 1&2 FamilyDwelling
City/Town,Sta
r— f M Masonry
RC Roofm Covering
ction Su ervisor's Si WS Window and Siding
�Q� p�j j gaatum or(Electronic Signature) SF Solid Fuel Burning Appliances
y yr � I Insulation
Telephone Email address I D I Demolition
5.2 Registered Home Improvement Contractor(HIC) /J�833
�d Z 01 L4'� / L C HIC Regiisstration ber xp' 'on Date
;Nd
mpan Name or HIC RegistrantNameStreet MC Registrant's Sign
wn, t te,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 .......... ❑ No...........❑
SECTION 7ar 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 half,in all in rel -veto work authorized by this building permit application.
le
dwher's Signature or �eT. of 5(Electronic Signature) Date
; 'SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my na7 below,I here attest under the pains and penalties of perjury that all of the information contained in this
application is and ace o the best of my knowledge and understanding. "
t r s or Autho ' d A eat s Name or nic Signature) to
NOTES:
1. 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(MC)Program),will not have access to the arbitration program or
guaranty fund under M.G.L.c. 142A.Other important information on the MC Program can be found at www.mass.2ov/oca
Information on the Construction Supervisor License can be found at www.mass.eov/dos
2. When substantial work is planned,provide the information below.
Total floor area(sq.R) (including garage,finished basementlattics,decks or porch)
Gross living area(sq,8.) 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"
BUILDING PLANNING - HEALTH • ELECTRICAL • GAS - PLUMBING • MAINTENANCE