122R BOSTON ST - BPA-16-301 3 25 o ��
�� °' '' I l00►'� S RECEIVED
The Commonwealth ofblassac it
t RVICkS
<� Board of Building Regulations and Standards CITY
Massachusetts State Building CoJOSOWN Q $ 26
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For Official Use Only
( Building Permit Numbers Date Applied
Building Official(Print Name). - Signature•: - Date
IZ B215MST SECTION Ii SITE INFORMATION
rru 11..1 Proper Address: / 1.2 Assessors Alap,dI Parcel Numbers
I.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: Ld Property Dimensions:LoningDistrict -•1.< Proposed Use - Lot Area(syit) Frontage(11) . .
1.5 BuildingSetbacks(R)
Front Yard . Side Yaids - - Rear Yard
ReyuintJ Providnl 'Required Provided- Required ` Provided
1.6 Water Supply:(M11.G.L o.40,§Sd) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Public O Private O - Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check If esl7 .
SECTIONN Z: .PROPERTY-OW.NERSHIPt:
2.1 w erm ecord:
. ���t�! r'7� �'�� �6u
time n it) ;7 City,;State,ZIP
No.and Strc6l - Telephone r' Email Ad It
SECTION 3:DESCRIPTION OF PROPOSED\VORW(check all that apply)
New Construction C3 Existing Building O Owner-Occupied ❑ Repairs(s) O Alteration(s) O Addition 0
Demolition. O 1 Accessory Bldg.O Number of Units - Other O Specify:
Brief Desc 'ption of Pr osed W rk': '
dL
SECTION 4:ESTIMATED CONSTRUCTION COSTS
M-
4. Official Use Only
Item
I. Building Building Permit Fee:$ Indicate how fee is determined:
Standard CiWown Application Fee
2. Electrical Total Project Cost!(item 6)x multiplier s
J.Plumbing ?Qther Fees: S
M1lcchanical (HVAC) ist:5.\lachanicnl (Fire otal All Fees:S
Sit ression) Check No._Check Amount: Cash Amount:
6.Total Project Cost: S ( 4' ❑Paid in Full ❑Outstanding Balance Due.
/ COY�fDtrJ�
31
Izz® c; r-tom
U'c7STo tJ '51
*SECTION"5: CONSTRUCTION SERVICES
5. unstruction Supervisor Lice (CSL) A p a
G �' / / r' � Cf' L License Number E!cpintti Dale
Name of CS Ho er ^ List CSLType(see below)
l�i � � « Description
1J Sim[
U Unrestricted 2 Family
a -el ing
\h V J y R - Restricted I&2 F:unil Dwelling
C ayfrovvn,State,ZIP M Maso
RC RoofingCovering
WS Window and Siding
SF Solid Fuel Burning Appliances
Tcle hone Entail address D Demolition
5.2 Registered Home Improv ent Contractor(HIC) / / / 0 !0 Z� ,v(
Il' vok CJ HIC Registration Num r spiral n Date
IIIZc�r/umpan ame or HI Registrunl Na. �J,n
No. ul 1/ ro
No. iJ St A ,t yv/ ',P I-PA E t address
or
C frown State ZIP LL! Telechone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G,lL e.152.$25C(0);
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Isivance of the building permit.
Signed Affidavit Attached? Yes.......... No...........❑
SECTION 7a.UWr4LRAUTHOR(4ATI1UN,T0 BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit appiica on.
ti r-l� C
Print Owncr's Name(Electronic Signature) Date
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[;�elflao
and accurate to the best of my knowledge and understanding.
A-r,D G ZZ
Print Owner's or Authorized Agcnt's Name(Electronic Signature) ate
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(HIC)Program),will n have access to the arbitration
P — — — —g
program or guaranty fund under M.G.L.c. Id2A.Other tin artant information on eN Yro ram can a oun �Y —
www mass eov;'out Information on the Construction Supervisor License can be round at wwvv.mass.nov,'dns
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. It.) Habitable room coma
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"'rutal Project Cost"