111 BROADWAY ST - BPA-2010-307 S
S
+� The Cummonwcalth of Massachusclts A*kV@NWNM
Board is Budding Regulations and Standards
a Ma55aC11U5e11S Slate BUllding Code, 780 CMR, T"ediaon Building Permit Application To Cunstruct. Repair, Renovate Or Demolish a
One-tar Tnu•Fumrli'Duelling
This Section For Official On1
Budding Permit Number Date 1
Signature: Ln�WWJ0
Building Commissioner/Insprct of Buildings Date
SECTION 1: sirfINWaRMATION
I.I Property Address: n � a 1:4 Assessors Map 6 Parcel Numbers
1.Is Is this an accepted street'?yes 60' no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning Distnct Proposed Use Lot Area(so;(I) Frontage(It)
I.S Building Setbacks(It)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood 2one1 Municipal O On site di sal system O
Public O Private O Check if sO p �o Y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: Y _ —
f(_cIVn/FT N O 1r!E" Y fmaaccum`f
Name(Print) Address for Service:
97$ 766 7388'
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK(cheek all that apply)
New Construction Existing Building Owner-Occupied el Repairs(') O Alteration(') O Addition O
Demolition Accessory Bldg. O Number of Units_ Other O Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Of lclal Use Only
Labor and Materials
I. Buildi 1. Building Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
2 Ell ecinca1 S O Total Project Costs(Item 6)to multiplier x
J Plumbing S 2. Other Fees: f
4. Mechanical (HVAC) S List:
s Mechanical (Fire S Total All Fees: S
Su ression
Check .No. _Check Amount: Cash Amount.
6 Total Project Cost S (Ilk 0 Paid in Full 0 Outstanding Balance Due'
r
SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construction Supersisor(CSL) 7z94 6 f f//
1Z1x00g
'' e /q.c"n1V,4W B % ip W4. Liceme.Numbw Esptr:mon Date .
N,,roe ul'CSL Hylder
-4 sH g 11:A6E l?R (' J71 -� List CSL Type lxc heluwl
rcsf Q !��-� T Description
AJd
0 U Unrestricted u to)5,000Cu. Ft.
n isLT R I Restricted 1&2 Family Dwellm
St MIYre %4 1 Masonry Only
g7 1 7f 3R 3Ft`�6 RC Residential Roofing Covens
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 R Istered Home Improvement Contractor(HIC)
isYRN — t�oA/STAdG-re oAl /2-75,43
HIC Company Naerie or HIC Re Istrant Name Registration Number
4vn,G�o l�L / 7i//� o19697 It J l,Z/.?-
Aadrss E tpiration Date
Signature —� ° Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. I52.1 2SC(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
thia afrdavit will resull in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes.......... No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
( 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.
Signature of Owner Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
Al '6 111?n1zF , astl w r 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. /� {�
/J R,&-A/7/9fl/ E7 9 XIZ--
Print Name /� z'^- O, r
/-� I/v„'G D Z v O
Signature of�or Authorized Age Date
(Signed under the pains and penalties of perjury)
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 W have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110 R6 and I MRS. respectively.
2. When substantial work is planned,provide the information below
Total Goon 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 halfbaths
Type of hearing system
of decks/ porches
Ts pe of cooling system Enclosed Open
1 Total Protect Square Footage"may he substituted for"Total Project Cost"
U,4 o
`T7? 745 647+
t ,
9`p
-zk�oPT,2 a,
-wo P��f 16 c ors
r