103 BROADWAY - BPA-09-481 �7 �'L7
The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
k! j Massachusetts State Building Code, 780 CMR, T°edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a ldd001106 06
01 One-or Tiro-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied: 12• l6'
Signature: 1-2.22-O n
Building C4mritlssione&Inspector of Buildings Date
SECTION 1: SITE INFORMATION
LI Property Addr ss• 1.2 Assessors Map& Parcel Numbers
422 k 0611*-Detz fi F
I.1a 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 R) Frontage(It)
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 ifyes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 wner of Records
BfJRRY m(den /03 B'floflP�u��y
Name(Print) f Address for Service:
7YS= 7 -2-�
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units / Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building g 0� el o I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
ry OU Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 60�, 13 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Lice nsed Construction Supervisor(CSL) 6Wi39 /_ /y-o70/G
+•� Expiration Date License Number Expir '
I ,
Name o(CSL-H Ider List CSL Type(see below) (/
7' Description
Address U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted I&2 Family Dwelling
Signature �J lT G 6 M Mason Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Re littered me I provement Contractor(HIC) 2 p4? 7
HIC COmpa'y Na a or HIC R gistt t Name Registration Number
lvl� 6 .a
Address g, Expiration Date
Signa Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.g 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 ......... No........... ❑
SECTION 79: 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: OWNEW OR AUTHORIZED AGENT DECLARATION
1 2_1, A—"- . ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.C
Print Nam
SignaturEZIrOwner or Authoriz gent Date d
(Signed under the 2ains and penalties of er'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 not 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 I I O.R6 and I IO.RS, respectively.
2. When substantial work is planned, provide the information below:
Total Floors 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 half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
i�