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16 BRIGGS ST - BPA-2008-794 SECTION 5: CONSTRUCTION SERVICES 5.1�Lyicensed Constructttion Superrvisor.(CSL) Gy�r7d-r�� _ /� _ �—Q � /ve/Y1/JC d LicensscaNumber Expiration Dale Narne of CS-fl Ider p List CSL Tvpe(see helow)Q T c Descn neon xd ress ,ram /,/y�._�J) A'�) U Unrestricted N to 35,000 Cu. Pt.t /�laAV / t Z/�1� � -- R Restricted l&2 Famil Dwelline Sig�aturc N 'visi Only R Rede C Rcsidenuul Rootln¢Cuvcnne Telephone W$ Residential Window ;ad Sidine SF Resldennal Solid Fuel t3urnine Appliance Instal l:u ion D Residential Demolition 5.21 Rggistered 1 ome%Jl�Improvement Contractor (HIC) jinn P (oil i/ ALL Registration Number f11C Com anyName or HIC Registrant N me © ry Expiration Date Signature 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 ..........19 No ........... SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby au i�/�� r � �� to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and behalf. Print Name 2=// p�J�O Signature of Owner or Authorized Agent Date (Si ned under the gins and enalties of er it ) NOTES: I. ,4n Owner who obtains a building permit to do his/her own work,or an owner .vho hires an unreaistered 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 and Construction Supervisor Licensing (CSLI can be found in 780 CMR Regulations 1 I0.R6 and 1 IO.R5, respectively. When substantial work is planned, provide the information below: Total Floors area(Sq. Fc) (including garage, finished basemendattics, 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" C The Commonwealth of Massachusetts �- Board of Building Regulations and Standards I.OR r t Massachusetts State Building Code. 780 CMR, 7°i edition NIUNIc'IP:V_I'll' U S F Building Permit Application To Construct, Repair, Renovate Or Demolish a Rrrlsrd Jonuurc One- or Two-Famih, Dlrelling 1. 008 This Section For Official Use Only Building Permit Numbe . Date Applied: Signature: _7t ? Building Commissioner/ Insifecuor of Buildings Date SECTION 1: SITE INFORMATION 1.1 V pert dress: l• 1.2 Assessors Map & Parcel Numbers / _ co L l:l Is this an accep .treet7 yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sy It) Frontage (it) 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:' Check if yes❑ Municipal ❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: /`' �6 ,, (` Name(Print) Address for+`i vice: Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(,) ld Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description if Proposed Work': r,. SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials) Official Use Only L Building $ / I. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ �00� ❑ Standard City/Town Application Fee ❑Total Project Cost' (Item 6) x multiplier x 3. Plumbing $ ®Q_ ?. Other Fees: $r 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Su ression) Total All Fees: $ Check No. Check Amount: Cash Amotmt: o. Total Project Cost: $ � �y pc.vi�� 0 Paid in Full ❑ Outstanding Balance Due: