13 BOW ST - BUILDING PERMIT APP 4 ,
The Commonwealth of Massachusetts RECEI ED CS
Board of Building Regulations and Standards INSPECti0t1A SEIi`��
Massachusetts State Building Code, 780 CMR SALEM
Rau s7v1�42011
Building Permit Application To Construct, Repair,Renovate Or]"d�Q a�
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date pplied: n
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 %roperty ss: / S� 1.2 Assessors Map&Parcel Numbers
1.la 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 Rem 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[]
f SECTION 2: PROPERTY OWNERSHIP'
2rn0 fR
r ame(Print) City,State,ZIP
3 r cc
,` /
No.and Street D `,J ( rj� �/2l L� �Yf
Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Afteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Speci
Brief Descri tionofProposedWork': p d
Qclo ✓
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ -Co 0 0 Paid in Full ❑Outstanding Balance Due:
-DJ z 1b C®N i • C t I 1
SECTION 5: CONSTRUCTION SERVICES j
5.1 Construction Supervisor License(CSL)JC jr. , 10
/1 L Z / /�
a J
p/9111 .� S License Number Expiration Date
Name of CSL Holder
"n",q,�� , List CSL Type(see below) 1.✓ s
No.and Street /"! RR
Description
stricted Buildin s u to 35,000 cu.ftJ
ricted l&2 F, Dwellin
Cityfrown,State,ZIP Maso
in Coverinow and Sidin
D Z C J �p (� �f� Fuel Burning Appliances
0ationTele hone Email address olition5.2 Regisstered Home Improvement Contractor(HIC) / /
HIC Company Name or Re ner HIC C Registrant Name dk�s HIC Registration Number Expiration Date
t
No. Street Pvl gw
a/E>, .�c�. ��^�� Emm add
/�/ 7
City/Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 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 .......... 12' No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED A=DECLARATIONNBy entering my name below,I hereby attest under the pains and penaltihe informationcontained in this application is true and accurate to the best of my know .Owner's or Authorized Agent'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.jov/oca Information on the Construction Supervisor License can be found at www.ntass.gov/dns
L. 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" a-o
t