51 BRITTANIA CIR - BPA gg I03 S
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The Commonwealth ofMassachusett SE' VICES
CITY OF
� Board of Building Regulations and Stand LE I
qYt I Massachusetts State Building Code, 730 CM11Rnn���� ��(( 22 A l�ew�e i ..2011
Building Permit Application To Construct, Repair, Renovat6'C7f 171, h a
One-or Tivo-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date p lied:
S R
Building Official(Print Name). Signature'-:
SECTION 1:SITE INFORb1AT10N.'
1.1 Property I?rw iS Assessors Map&Parcel Numbers
I.I a Is this an accepted streetl y no Map Number Parcel Number
�1 1.3 Zoning Information: IA Properly Dimensions:
\� Zoning District Proposed Use Lot Arco(sq R) Frontage(Il)
Zo
.1I 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:
l Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP!
I Ownert�gf eyrord: J
1`Cha�cF 6,iNac.
tV�hme(Print `r City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ A •essory Bldg.❑ Number of Units Other ❑ Specify:
Br4D gscription of Pr pose \
2.
�N Sall 11 8h t in
k1
SECTION 4: ESTIMATED CONSTRUCTION COST
Item Estimated Costs: Official Use Only
Labor and Materials)
1. Building $ I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard Citylrown Application Fee
2. Electrical $ ❑Total Project Costs(Item 6)x multiplier x
3. Plumbing S 2� Plher Fees: .S
4,Mcchanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees:S
Su ressiun)
c Check No._Check Amount: Cash rlmotmt•.
6.Total Project Cost: S 7 ❑Paid in Full ❑Outstanding Balance Due:
moI E:D Tt� N . o.
,
SECTION 5: CONSTRUCTION SERVICES
5.1 nstruction Sup isur Lic1cnseL(CSL)
bbQr `[ DCZfifyo f License Number Expiration Date
Namr'e�of CSL Holder
List CSL'fype(see below)
p, 1¢ L Type Description
No. .mdStrcet U I Unrestricted(Buildings up to 35,000 cu. 11.
VVV bIF-7b R I Restricted )&2 Family Dwelling
6tyfrown,State,ZIP M Maso
RC Roolin Covering
WS Window and Sidin
/�qq t` SF Solid Fuel Bruning Appliance
L 6 v to l " a l�� 1 Insulation
Telephone Email address D Demolition /
5.2 Registered Home Improvement Contractor(HIC) /a �
HIC Registration Number Expiration Date
HI�$L pan qr 11IC Reg(stint Mil
NVi,M ly3 bdry ,ma yal 6g9- aU39 Email address
City/Town,State ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.I52.§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 I !u a of the building permit.
Signed Affidavit Attached? Yes ....... ..(1k No...........❑
SECTION 7ar OWNER AU RIZATION.TOBE.COMPLETEDWHEN!
OWNER'S AGENT OR CONTRACTOR APPLIES FOR p BUILDING.PERMIT
f`1 `
I,as Owner of the subject property,hereby authorize MG cb C. I O T
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
S E E r—ry\ t� �0- 5'
Print Owner's Nmne(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
Pon awpwed iin/this ap )icuuon is true and accur to to the best o my knowledge and understanding. c� .
r7�1t C > SIC n J&,J— 5
Print Owner's Authorized Agent's ante(Electronic ignature) 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 n�f have access to the arbitration
program or guaranty fund under 1M.G.L.c. 1 d2A.Other important information on the HIC Program can be found at
www m tss eov'oea Information on the Construction Supervisor License can be found at ww%v.nmss.,,ov'dos
2. When substantial work is planned,provide the information below:
'total tloor area(sq. R.) 'r (including garage,finished basement/attics,decks or porch)
Gross living area(sq. tt.) 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 orcoolingsystem Enclosed Open
3. `Total Project Square Footage"may be substituted far,,rot:d Project Cost"