103 BROADWAY ST - BPA-16-859 339
The Commonwealth of Massachusetts
Bard i p rY x fV.t'' CITY OF
o of Building Regulations and Standards,�t �,�� , .,�.y A
Massachusetts State Building Code 780 CMR � -)EM
a Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate J0tbD# a i�. 5p
1 One-or Two-Family Divelling
n This Section For Official Use Only
Building Permit Number: Date pplied:
Pof-�°
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Proper[ Addr s: 1.2 Assessors Map& Parcel Numbers
J,o�d 6pTA �y S741J2144
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 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 ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2. Owner'of Record
t 4 ZEN leg Sdewl . MA O
Name(Print) City, State,ZIP '��
/o 3 34- 9 70- 7 yS—c;�4 IS
No.and Street I Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK' (check all that apply)
New Construction❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) P1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work'-:
t
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
L Building $ ��' 1. Building Permit Fee:S 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: $
S`3 Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ❑ Paid in Full ❑ Outstanding Balance Due:
Mkl g
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 7
kr l:—a�- kq ,�_w Expirati Dat
Name of CSL Holder
M1 i List CSL Type(see below)
No. and Street Type Description
� �� �j/t U Unrestricted(Buildings u to 35,000 cu. ft.)
V R Restricted 1&2 Family Dwelling
City/Town, State,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 0 1 /0 6 �
4 I t ry r&Ql &-S HIC Registration Number E. irati Jn Date
HIC Compa Na e or HIC egistrant Name
( ,� �'h ,C
No1.ind 1,treet Email address
City/Town, State,ZIP 11 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 he building permit.
Signed Affidavit Attached? Yes .......... No ........... ❑
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
to act on my behalf, in all matters relative to work authorized by this building permit application.
See cc�k c a�
Print Owners Name(Electronic Signature) Oate
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Naine(Electronic Signature) ate
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 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
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
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. 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"