3 BOW ST - BPA-14-708 1 -'108
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The Commonwealth of Massachusetts SE VlGE$
� CITY OFF
Board of Building Regulations and Standards pey +�l� A
I. / Massachusetts State BuildingCode, 780 CNIR 38
a' �R R1N41 I /If1
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For Official Use Only '
Building Permit Number: Date Ap ied:
B
uilding 011iciul(Print Name). _
SECT Sir.
I:SITE INFORtNIATION'
1.1 Prop rty Addres 1.2 Assessors binp 3r Parcel Number
w
1.1 a Is this an accepted street?yes no Mup Nurnbcr Porcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Lot Area(s it Frontage 11
"Letting District Proposed Use 4 ) g ( )
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard !
Reyuired 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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes13
SECTION 2: PROPERTYOWNERSHIP,l
2 Owner of Record:
� panPal �a�Pn,, 6t57D
N me(Print) City,Slate,ZIP
3
No.and Street Telephone L•muil Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work: L
O
SECTION l: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials)
I. Building S ' ,��� I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S Q ❑Total Project Cost'(item 6)x multiplier x
3. Plumbing $ 1a 00 2. Other Fees: .S
d.Nicchanical (IW\Q S List:
5. Ntcchmtical (Fire S �� roudAII Fees:S _
Suppression)
Check No._Check Antuunt; Cash Amount:_
G. Tutai Project Cost: I �(�(� Cl Paid in Full ❑Outstanding Balance Due:
(M Al t_tv je,� i I M 0A N S A
b11NT"FkE D Oigy U
3Y13338
Z331 f n2c r•ru" 557;il SECTION 5: C•ONSTRUCrION SERVICES
5.1 Construction Supervisor License(CSL) ! 4�
e f ' r,1 L License Numbcr E.r ruti Date
t C t 4
Name orC L[folder
t
�� List CSL'fype(see below)
G✓1 ^ Type Description !
Nu.unJ Street
Mfl (�1��"\ U Unrestricted2 Family
(Buildings u to 35,OW co. Il.
�'''�� V Restricted lSc2 P:unil Dwelling �
C tyf ttvn,Scue,ZIP wl Masonry
RC Rooting Covering
WS Window and Siding
ry) Sr-��S�N�+J.N tOC SF Solid Fuel Duming Appliances
5/YIAP.! I. C',�l 1-1 I Insulation
Fcle hone Email address U Demolition
5.2 Registered Home
fIIC ImprovementContractor(11IC) l34
e S A� W n r HIC Registration Number Es iru ion DonehnnRmC Registrant Nmne
\-1 -1 fV c lr\ �� y��j WrS�I t�1JA/Inta\G��+1 C \
No.alstreet Email address
A-A —
� 0\ oGKJ 41 ?,;-a 31
Cit frown,State ZIP Telephone
SECTION 6:WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 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 lstuan2flhe building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION.TO HE COMPLETED WHEN.
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PER611T
[,as Owner of the subject property,hereby authorize U e c �.RA t e
t9 act on my behalf,in all matters relative to work authorized by this building permit ap cation.
_�, 31 N
Print Owner's N:mre(Electronic Sign ) bate
SECTION 7b:OWNER[OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's t ne(Electronic Signature) Mae
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who Itires an unregistered contractor
(nut registered in the Home Improvement Contractor(111C) Program),will not have access to the arbitration
program or guaranty fund under NI.G.L.c. 1 a2A.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 wvaw.ntass.gov:'tlyty
�. When substantial work is plumed,provide the information below:
"total tloor area(sq. 11.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplaces" Number of bedrooms
Number of balhrounts Number of half/baths
T,vpe of he;uing system Numbcr ufdecks/porches
l'ype of cooling S)Acnt Enclosed Open_
3. "I'olal Project tiyuare Footage"may be substituted litr'ToLtl Project Cost"
I