21 BRIGGS ST - BPA-2010-141 v The Commonwealth of Massachusetts Town of
i L Board of Building Regulations and Standards
j CIt`� 'Massachusetts State Building Code, 780 CMR. 7"edition Building Dept
I Building Permit Application To Construct. Repair. Renovate Or Demolish a
On r -Fumih Duelling
This Sectio For Official Use Onl
Building Permit Number: Dale Applied:
Signature:
Building Co tssione Inspect u logs Date
ION 1:SITE INFORMATION
1.1 Property Add r 1.2 Assessors Map h Parcel Numbers
Ma Number Parcel Number
1.1 a Is this an accepted street'?yes 'no P
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq n) Frontage(fl)
1.5 Building Setbacks(ft)
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: I.g Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public O Private O Check if es❑ —
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownerl�eftReco��� t /�
Name(Print)'+ ,C}LL Address f r Servicr.
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all at apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ 1 Number of Units_ Other Q Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
1. Building f 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Ile 6)x multiplier x
3. Plumbing S 2. Other Fees: fla-h
4. Mechanical (HVAC) $ List:
5 .Mechanical (Fire S Total All Fees: S
Su ression
Check No. _Check Amount: Cash Amount:-
6. Total Project Cost: S Paid in Full O Outstanding Balance Due:
If2rd6L 'Z�a f 'eu
SECTIONS: CONSTRUCTION SERVICES
5.1 Licen `Construct/ penisor(CSL) ^2 / la
a A4�sI'T C Llccnx Numbcr��' Eapuauon ai
N- C6.) I er I
LI+t CSL Type(see below)
Addss NDIResidential
Descn tion
�-qqretncted u toJS000Cu. Fr)
'�Istncird I&2 Famd Dllm
idential Roofin CoverinTelephone idential Window and Sidinidential Solid Fuel Burnin A liance Installation
Demolition
5.2 Registered Hom vein o Con ratio HIC) ^r /j
HIC Company Nlarnel, Illegistrairi-I Nanneration Numb r
A ss !
Eapirauy b to
619 m Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 2SC(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 o e building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7— 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.
Si nature of Owner Date
SECTION 7b:OWNER/OR AUTHORIZED AGENT DECLARATION
I• -,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing app ication are true and accurate, to the best of my knowledge and
behalf.
Print Name
SignafaffV Oqfnir or Aull(brized Agent , Date
(Signed under Ite pains and penalties of per 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 W 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(CSL)can be found in 780 CMR Regulations 110 R6 and 110,R5, respectively.
2. When substantial work is planned,provide the information below;
Total noors 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 halfibaths
Type of heating system Number of decks/porches
Type of cooling system - Enclosed Open
1. 'Total Pro)ect Square Footage'may he +uhstituleJ for 'Total Project Cost"