1 BOW ST - BPA-2010-247 DOOR � 6
V I Q The Commonwealth of Massachusetts Town of
C Board of Building Regulations and Standards
. � .Massachusetts State Building Code, 780 CMR. 7'"edition Building Dept
` Building Permit Application To Construct. Repair, Renovate Or Demolish a �
One- Atri-Funu(r Littelling
is ection For Oficial Use Of
Building Permit Number: D to plied:
P.
Signature:
Budding Commis - ner/ nspec o Buil i g Dau
SE TON 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Number
115 r� t–✓ � T– Parcel Number
I.1 a Is this an accepted street!yes_ no Map Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use
Lot Area(sq 11) Frontage(ft)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Public O Private O Check if vesO
SECTION 2: PROPERTY OWNERSHIP'
----------------
2.1 Owner of Record:
T�TC f d
Name(Print) Address for Service:
9 C 0 9 7L428
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Buildin Owner-Occupiet�_ Repairs(s) O Alferation(s) O Addition O
Demolition O Accessory Bldg. O Number of Units Other O Specify:
Brief Description of Proposed Work': o — - o
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Ofltclal Use Only
Item Labor and Materials
I. Building f 1. Building Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
2. Electrical f O Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $
4. Mechanical (HVAC) $ List:--------------
a
t Mechanical (Fire S Total All Fees: f
SU .e ..nn
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: S 510 D a et� O Paid in Full ❑Outstanding Balance Due: -
�o U ( cG , 4 , ,,
l
SECTION S: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) Q 9(-?-?b3 _ ( l/e �d
License Number Eapuauon Dam
r
N.;1mc of CSL- HplJer
( �( � List CSL Type(see below)
AJJrrss T' Desert non
U Unr it "ed u to 75.000 Cu. Ft.
R Rrstnctrd 1&2 FamJ Dwellm
Signature M ,Mason Only
S —,I ( �a 3y RCRCSidennal Roofin Coverin
Telephone WS RrsiJenuaI Window and$idm
SF Residential Solid Fuel Burning Appliance Installation I(
D Residential Demolition tl
S3 t{egistered H�e Improvememt Contactor(HIC)
LV
HIC Company Name or HIC Registrant N Registration Number
Addr�a��-.��--�� n
v--l�l`� 3 1cg�Zy Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 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 .......... O No........... O
SECTION 7s: 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 behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
/�SECTION 7b:OWNEROR AUTHORIZED AGENT DECLARATION
LYC,�,,.-t- ,as Owner o Authorized Agent ercby 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 o Authorized Agent Date
(Signed under the aims and nalties o (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'• have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the NIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and I IO.RS,respectively.
2. When 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 halfbaths
Type of heating system Number of decks/porches
Ty pe of cooling system Enclosed Open
1. "Total Project Square Footage"may he substituted for 'Total Project Cost"