21 BRIGGS ST - BPA-2009-542 The Ck i nnomvealth of NILISSaChLISMS ---
41\ Board of 131.111ding Regulations and Standards
Massachusetts State Building Code. 7SO CNIR. 7"'edition
LR lit ildin_ Permit Application To C'unstrurt. Repair. Reno,,ate Or Demolish a RI,;,, 1 h;,u„r„
(btt - of Tn' -bunt' v Drrr(lilig /. -i°'•�•.
I'his Section Fur tticial Use Only ---
Bu11Jine Permit NL iber: _ ate .Applied: j
Sien:aure: �� 3h/ems
BulldIng Cununls,un)el/ In>prrn r H Bull 1 Date
S I: SITE INFORI\IA I'ION
1.1 PropeM l Pess: � c .._ 1.2 Assessors .\lap & Parcel Number.....----_—__--
I.1 a hs this all accepted meet" yes 1 o Map Numher P:u.el .\uinhrr
1.3 Is
Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(+y it) Flunlage III) ---
1.5 Building Setbacks (fU
Front Yard Side Yards Rear Y;u Ll
ReyuircJ Provided Reyes red Provided Reyuued Pro,IJaJ
1.6 Water Supply: I M.G.L c. 40. §54) 1.7 Flood Zone Information: LS Sewage Disposal System:
Zon _ Outside Flood Zone''
Public ❑ Pn ate ❑ Check if yes❑ Municipal ❑ On site disposal syslcm ❑ -_1
SECTI 3N 2: PROPERTY OWNERSHIP'
�2.1 Owner'of Record: / L,5 r �
Address for Servic•:
i 2& —
Stgnaulre Telephone f ----
O SECTION 3: DESCRIP ION OF PROPOSED WORK(check all that apply)
New Cunstructionl,C ExistingBuilJingO Owner-Occupied ❑ Repalrsls) ❑ Alteratum(s) ❑ \JJili,m ❑
Demolition �'❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated : Official Use Only
I Labor and Materateri list _
I. Building S I. Building Permit Fee: $ Indicate how tee iSJcter fill fled: j
❑ Standard City/Town Application Fee
2. F.lectricaf S ❑Total Project Cost' (Item 6) x multiplier x _
J. Plumbing 3 I. Other Fees: .5
4. Mechanical (HVAC) S List:_
5. Mechanical IFirel y -----------
Su t resston) Total All Fees: S
Check No. Check .\mount: C;uh Amount
Cost
5
i I, -Fatal Project C ���. 0 Paid in Full ❑ Omst:utding B;dance Due:---_--
�.1 Licensed Col SECTION 5: CONSTRUCTION SERVICES �
hstruclimt 5upenisor/6C' '1.1
-- —_ �`G '/e License suuther F\piruinn Dale
f ;ante nl (,SL. I IuWef / 1..1.1 CSI_ 1'�pe(,rr hehtw)
L!
I __._. 'I\ c Desen ,uon _
\JJr ,IC I'In e>U Icled rn p it, Is.(9)U('u Ft.,
R Rcstovted *' F.unll\ Dttillin_e
_ RC Re,IJrnual Rurilinc l'u.......
I eleph�ne \CS RC,Ideut I al \\1 nJ,ia ,slid SIJ111Y_
�-- SF Re'lJennal SobJ 1-url I3urnule \ I_mec In.I.J l,tl�_n y
D 1 Re.IJenlial Uen,ohown
5.2 Registered Ilome Intprovernenl Cunt actor IIIIC)
HIC Company Nall or H ' Rc s(raltFaine
Regnu auu Nun,hrr
/ y ('�( ,
S,gnmure re(ephune
SECTION 6: WO KERS' COMPE SATION INSURANCE.AFFIDAVIT (M.G.L. c. 152. § 2506)1
Workers Compensation Insurance affidavit rust be completed and submitted with this application. Failure to pro.,de
(his affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached'? Yes ......... ❑ No ........... ❑
SECTION 7a: OWNER AUTHORIZATI N TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
cS fi as Owner of the subject property hereby
I' - -- to act on my behalf, in Lill nutters
;uthormcL
relative to w•.;,k authorized by this building permit application.
Date —
Si nature ol'Owner
SECTION 7b: WNE r OR AUTHORIZED AGENT DECLARATION --
�� , as Owner or Authorized Agent hereby declare
ce-
that the statements and information on the fo egoing application are true and accurate. to the best of my knowledge and
behalf.
Print Name _ a I
Date
Signature of Owner or Authorized: " t
(Signed under the pains and penaltieS of Pffjtl ) NOTES:
I. An Owner w'ho obtains a building permit to do his/her own work. or an owner who hires :u\ e� )sicced o ntru•tr
r
(nut registered in the Home Impruveme t Contractor (HIC) Program), will not have access m mC arbitration
program or guaranty fund under M.G.L. IJ'_A. Other important inhumation on the HIC Program and
Construction Supervisor Licensing (CS )can be found in 780 CMR Regulations I IO.R6 and 1 10 RS. respeco.cly.
' When subslamiai work is planned, prove a the information below: j
Total flours area(Sy. Ft.) _(including garage. finished basentenUatocs, decks or porch,
Habitable room count
Num living area i Ft.) Habitable
of hedrnu,m, _
----------
Number u(iuepl°1es Cs Number of h,,IUb.uh,
Number of hathnton)s
Number o(Jecks/ p„rehn
I',pe of hearing system —
hnclu,ed
Type ut cooling ,y,lem — --- --
t "Tolal Project SyU:ae Footage" may be ubstituted fur 'Tend Project Cost"