161 BOSTON ST - BUILDING JACKET The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
4y Massachusetts State Building Code, 780 CMR, 7'"edition Wilbraham
Building Dept
Building Permit A ation To nstmct, Repair, Renovate Or Demolish a 413-596-2800
One- or Two Farrrily Dwelling Ext 118
.This Sec on For Official Use Only
Building Permit Numb III Z A Date Applied: �'1 0 • 0
Signature: U'
Buildi gCorr tssioner c Buildings Dates
SECTION 1:SITE INFORMATION
1.1 Property Address:`� 1.2 Assessors Map& Parcel Numbers
\bkQ,3�r, I1
1.1 a 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 R) Frontage(ft)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes[]
_ SECTION 2: PROPERTY OWNERSHIP' _
2.1 Owner'of Record: p
Name(Print) Address for Service: -
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 Existing Building Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑ _
Demolition ❑ P.ccessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed WorkZ 50
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building s c6)�j -� 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) S List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Chec!Amount: Cash Amount:
6. Total Project Cost: S paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) NQ\S—\y
W��� er`� S�Ay\ License Number Expiration
Name of CSL-Holder
u\^ o 4" List CSL Type(see below)
Address �.1_/ Type Description. t
U Unrestricted(up to 35,000Cu.F .)
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Ccverinng
Telephone wS Residential 'Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
� � D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
� ��>__� Comet _
P.IC Company Name or HIC gNgistrant Nafh 10
1� Registration Number
Adair.->s - - --
Expiration at
Signa ure — — eleahonc
r SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insumnee affidavit must be completed and submitted with this application. Failure to provide
his affidavit wiltresult in the denial of the Issuance of the building permit.__ _ —
5igued A:"'idavit Attached? Yes ........ IYQN No ........... ❑
SFCTrON 7a: r PWNER AUTHORIMMON TO BE COMPLETED WHFN --- ------- ---i
j OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT .
as Owrier of the subject property Iteieb.
au no Ze �\A. �yC"- Tlr— _____- to act on my behalf, in all matters I
i -e' !s aut'iorized by this btulding peanit.apiiii,ation. -
�'
of lea
SECTION?b: OWNER' OR AUTHORIZE,—) A.-'ENT DECi.,ARATION
as Owner or Authorized Agent hereby declare I
-hat the statem nts and information on the,, foregoing application are true and accurate, to the best of my knowledge and
Print Na±nc
[ig-riOn 0170 wtier or Authorized Agent --_--_---- Date
rl� d under the pains and penalties of perjury)
NOTES_
I. .%n Ovmer who 'otairs a building permit to do his,/her own work,or an owner who hirer an-unregistered contractor
( e,
not.cgistered in the Hem: Improvement Comiactrr(HIC)Program), will nor have access:e [he arbitration
srogram or guaranty fund under M.G.L. c. 142A. Othrr important information on the HIC Program aad
2.Construction Super;isor Licensing(CSL)can be found in 780 CMR Regulations 110,R6 and 110.R5, respectively.
Wher! substantial work is planned,provide the information below.
Total floors 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
Type of beating system Number of decks/porches_
Type ofcooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"