1 BOW ST - BPA-15-727 WINDOWS/SIDING GK 9 ( g�
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The Commonwealth of MassaclipfricL,,I%IL-D
SgCTIONAL SERVIC'
4 Uk Board of Building Regulations and Standards S
,\ M 1 Massachusetts State Building Code,7$�[�CMR
I n /�
\U -*01
Building Permit Application To Construct,Repair, Renovat&?9'emAisU.3
_1 One-or Two-Family Dwelling Rev. Sept 2014
v This Section For Wicial Use Only
Building Permit Number: ate Applied:
( n
Building Official(Print Name) Signature Date
c+9 SECTION 1:SITE INFORMATION
L 1.1 Pro erty Address• 1.2 Assessors Map&Parcel Numbers
( �C9(.J
L l 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 ft) 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 a 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 Own r Record:
of Rd:
-+f1) V rags Sc� letpl , MA Ofgr7o
Name(Print) sJ City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repaus(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': ti S' vin Sr d
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 6 1. Building Permit Fee:$ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
n Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ a 6 613. ❑Paid in Full ❑ Outstanding Balance Due:
R1Sa
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) V y /^ ^/ 3
br 1 S Z()r 2-:Y License Number Expiration Date
Name o CSL Holder
I � 's- p r)r List CSL Type(see below)
No.and eet l\/ Type Description
n �� n/J /L /1� I U Unrestricted(Buildings u to 35,000 cu.ft.)
(.� M �f l 6 R Restricted 1&2 FamilyDwelling
City/Town, te,ZIP�� M Masonry
RC Roofing Covering
VVV—� WS Window and Siding
SF Solid Fuel Burning Appliances
U/ Cf I Insulation
Telephone Email address D Demolition
5.2 Register d Home Ira rovement Contractor(HIC) /014 0
61 HIC Registration Number Expiration Dale
Mucci any t me or IC Re is ran[Nem
No.142r e1 1� !! Email address
f V 9V:Jyl-oy�Y
Ci[ /Town, State,ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.5 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 f the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize C t'1 h � —Z ole z J
to act on my behalf,in all matters relative to work authorized by this building permit application.
lPe CO!n yad-- 1- 1-7- 1S
Print wner's Name(Electronic Signature) Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
Bye I below,I hereby attest under the pains and penalties of perjury that all of the information
contained in i a plication is[ e and accurate to the best of my knowledge and understanding.
AY
iPnnt-Owner's or.. uthorized-Aaent'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
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.aov/dos
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. 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"
The Commonwealth of Massachusetts
a 1= ! 6 Department of Industria!Accidents
Office of Investigations
Mrf ', 600 Waskiiii Street, 7 Floor
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractors
Applicant information: Please PRINT legibly
name: lrl.0>C'1�c)l2 .
address' //Z5 (V-0,-7% 7/ -eel!
cit Scale t , smte' MA zip' 61970 phone# �sr--71//-eLA9
work site location(hdl address): I &, kJ S"(- �O(1 e- fqfi- Q 17 -76
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction ❑Remodel
❑ I am a sole proprietor and have no one working in any capacity. ❑ Building Addition
21 1 am an employer providing workers' compensation for'my employees working on thisjob.
comnanv name: 4fr'/1-- � l Q I/)/1 �SZ-S /61 c
address' f 15- t t/O w -f7n (� p [ ' / �7
city' So, i IF (M'' �7M�.'� phone#; r-�t �7t 9- 7pk �Q'/�`! 0'-7
'nsuranceco I L,-4 ( ;rave I-e - '.S policy# t_ ;; Lt � rv1 V 1 5-
❑ I am a sole proprietor, general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers' compensation polices:
company name:
address:
city: phone#:
insurance cor. policy#
company name:
address:
city: phone#:
insurance co policy#
Attach additional sheet if necessary
Failure to secure coverage as required under Section 25A of 1101. 152 can lead to the imposition of criminal penalties of it fine up to Sl500.00 and/or
one years'imprisonment as well as civil penalties in the form ora S"rOP WORK ORDER and -fine of 5100.011 a day against me. I understand that a
copy of this statement maybe forwarded 7theffice ofInvestigations of the DIA for coverage verification.
t do hereby certify aur a trr pains mues of perjury than the information provider/above is true and correct.
SignaWrc � � `
Date -
�
�7 pq e �y
Print name ✓ C�� / L O✓Z..-/ Phone# 7 O 7
-z .. -.
official use only do not write in this area to be completed by city or town official
city or town: permit/license# ❑Building Depot(ment
❑Licensing Board
❑check if immediate response is required ❑selectmen's Office
❑Health Department
contact person: phone#; ❑Other
(revised Sepi.2001)