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53 BRITTANIA CIR - BUILDING PERMIT APP The Commonwealth of Massachusetts Board of Building Regialatious and Standards CITY OF Massachusetts State Building Code, 730 CNIR SALENt )� 71 Revised Mor 2011 1 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Family Duelling This Section For Official Use Only. Building Permit Number: I Date ApplE `,> y Building Official(Print Name) 'Sig tur - - Data - SECTION I:SITE INFORM IY. 1.1 Property ss: 1.2 Assessors Map & Parcel Numbers l.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 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? Municipal❑ On site disposal system Cl Check if yes(3 SECTION 2:, PROPERTY OWNERSHM 2.1 Ownert of R � Name(Print) ^I City,Stat�� S-0 4 44 C,retie l� No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORIe' check a at apply) New Construction ❑ Existing Building❑ Owner-Occupied Cl Repairs(s) Alteration(s) ❑ Addition Cl Demolition ❑ Accessory Bldg. Cl Number of Units Other ❑ Specify: Brief Description of Proposed Work': r � , ZN SECTION 4: EST IVLvrEDCONST RUCTION COS S Estimated Costs: [rem Official Use Only- Labor and Materials I. Building $ I..Building.Permit Fee:S indicate how fee is determined: 2. Electrical $ ❑:Standard.Cityfrown Application Fee ❑'rotal Project Costs(Item 6)x multiplier x J. Plumbing i 2_ Other Fees: S 1. Mechanical (IIVAQ S List: - i. Mechanical (Fire $ - SnP aression) _ lbtal:\Il Fczs::S Check No.qlWlicek Amount: Gash Amami_ t1 To Project ❑ Pa tal Prot Cost: $ . i �S l ul in Pull 0 Outtandua�" IJ:dance I?ud: srcrlON 5: CONSTRUCTION SERVICES 5.1 Construe ' n Supervviissuur License(CSL) - Q } ]t - a�fLicense Number t E.epir+ wn Date Name of CSL Ilulder List CSL'rype(see below) —1 t J w, Y `�//� Type De cription No. and Street U Unrestricted(But ldings up to 35,000 cu. R. R Restricted 1&2 Family Dwelling Ci(ylruwn, S� iv1 blasonr RC Root-in Covering WS Window end Sidin SF Solid Fuel [3urning Appliances [_hone I Insulation l'ele Iona Email address I D Demolition 5.2 Registered Hone Im rov menu 4qontra HIC) �? HIC Registration Number E. ''anon Uate 111C Cot %State, 11C c I' No.and Str ©I Email address City/Town, Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152.§ 25C(6)) Workers Compensation Insurance affidavit must be co pleted and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuan of the building permit. Signed Affidavit Attached? Yes ........Id No........... 13 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property,hereby authorize b'A 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: OWNERI OR AUTHORIZED AGENT DECLARATION By entering my name below, [ hereby attes n er the pains and penalties of perjury that all of the information conta a m this a lication�is true and cur a the est o my knowledge and understanding. Print 0%vncr's or Authorized A;cnt's Name( lectrunie ignature) NOTES: I. :1n Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Finale Improvement Contractor(HIC) Program), will not have access to the arbitration program or,guaranty Rind under M.G.L. c. 142A. Other important information on the FIIC Program can be found at av way.m;us.� uv oca Information on the Construction Supervisor License can be found at ww•ay.mass.a L111vi• 2. When substantial work is planned,provide the information below: Total floor area(sy. tt.) _ —(including garage, finished basement/attics,decks or porch) Grog; living area(,y. ft.) _ Ifabittblo room count _ Miniber of tirrpl,lecs,-.--_--- Number of bed oonis Vuntherufb,ulunums Nuuifierofhalt'baths - __—_— fepe ot'lleating system . .. - ._- ----_ _-- Number of decks/ porclus --- _--------- pcot,cooling ,yaeua — finelo:at. —__ open 4. betel Plo :rt S, u.ua Pn,rt I,e i11 ry he iubitirl[:,d t;,, 1'�d.il I inject C'ost'• I I ,.