30 BROAD ST - BPA-11-817 The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEhy
'4( Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Per
t NNuu"mberr': Date Applied:
Building Offcial(Print Mine) Signature Date
v V SECTION l:SITE INFORMATION
1.3g P � �s � 1.2 Assessors Map& Parcel Numbers
I.I a Is this an accepted street?yes no Map Numtwx Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sy It) Frontage(11)
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 yes0 Municipal CIOn site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
S4,e ,.., MA Zy
Name(Print) City,State,ZIP
3o Orogg S k 1-47q-- q79 -970
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repaus(s) f13' Alteration(s) ❑ Addition Cl
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': U
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I, Building $ r 13 1. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $ / 000. n ❑Standard City/Town Application Fee
❑Total Project Cost,
ost (Item 6)x multiplier x
3. Plumbing $ ysddtd� 2. Other Fees: $
4. Mechanical (LIVAC) $ List:_
5. ,Mechanical (Fire $ _
Suppression) Total All Fees: $
/' 3 Check No. Check Amount: Cash ;\mount:
6. Total Project Cost: $ �� �j7 r / ❑ Paid in Full ❑Outstanding Balance Due:
C d�
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) t C)CC
I l „VAA, E �p�eS License Number Expiration Date
Name off CSSL l folder �-T
List C'SL'Fypc(sec below)
a� •�"'r ` 'type Description
No.and Street
�7 y� O`/3 O� U llnrestricleJ(Buildings u' to35,000 cu. tl.)
ww\p�G1Yh 1 ' IA 'l R Restricted IK2 Fwnil Dwelling
Pity/Town.State,ZIP M Nlasonry
RC Roofing Covering
WS Window and Siding
I SF Solid Fuel Burning Appliances
?&'—�jq�-y 3(g I Insulation
Telc hone Email addrus D Demolition
5.2 Registered Home Improvement Contractor(HIC) -
"[{r�OMr] �C'lOty I1IC Registration Number Expiration Date
I IICConipan Nanm or IIIrIIC Registrant Name
No.;asid
ePtw.(�SZt� m� cl fr_y 3(glj [mail address
Ci /Town, State,ZIP 01-t0 I 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 .......... l@r No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property, hereby authorize�A-6 E: cg
to act on my behalf,in all matters relative to ork auNth 'E by th's building permit application.
�CCvIW �0�6 uI, o J A S� q- t
Prnt owner's Nmne(Electronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering lny name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accur o the best of my, knowledge and understanding.
76M
Print Owner's or,\uthorized Agent's Name(Eleluqflonic Signature) V Dale
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 not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program can be found at
t,ww_nru,.gov_'nca Information on the Construction Supervisor License can be found at tTt�w.nt:u ,aos'dos
2 When substantial work is planned, provide the information below:
Total floor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. a.) Elabitable 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. "Focal Project Square Footage"may be substituted fir"total Project Cost"