6 BROWN ST - BPA-2010-928 r y
The Commonwealth of Massachusetts
} Board of Building Regulations and Standards CITY
p / Massachusetts State Building Code, 780 CMR, 7'"edition OF SALF:M
U 1,y ReviseJJainsart-
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 2oov
One-or Two-Family Dwelling
11 This Section For Official Use Only
Building Permit Number: Date Applied: /0
Signature: / � re V
Buildin Commissiter/Ins of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address:ok3n 1.2 Assessors Map& Parcel Numbers
6 >3 R
I.la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zonlag Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq B) Frontage(it)
1.5 Building Setbacks(R)
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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2. Owner of eco Jog" Z / ��
ame( tt dress for SeJ(vice: /'�
Si a elephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction O Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) O Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other O Specify:
Brief Description of Proposed Work: act c t to w/ nard
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S 38rx-� 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cosh(Item 6)x multiplier x
3. Plumbing is 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
3 �(r Check No. Check Amount: Cash Amount:
6.Total Project Cost: S ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) L.S OR o818
I�.e r CONE— License Number Fspiration Date
Name of CSL- I lolder List CSL Type(see below)
10(o fVORN- Amgw 7 r. Description
.4JJrcss U t1mcstricteJ a w35,000 Cu. Ft.
R Restricted 1&2 Family Dwelling
Signature M Mason Only
; RC Residential Roofing Covering
felephone ` WS Residential Window and Sidinit
SF ing Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
(-dLg� GoNS"rRU(.IN Registration Number
HIC Company Name or HIC Registrant Name
w6 watr-t- ST mrsaForir� �Jo I I
Address
Expiration Dale
Signature Telephone -
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.&C. 152. 1 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 ..........0 No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OW
N
ER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 /// G� J`GTC�-�/// . as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relati t ork a ri ad by i 'Iding permii application.
gnaturc of Owner Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
I ,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.
1 �6v VV C-O' lvUr
Print Name
Signature of Owner or Auth 'zed Agent Dale
(Signed under the sins d nalties of 'u
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hircs an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program), will Wj 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 1 IOA6 and 110.RS, respectively.
2. When substantial work is planned,provide the information below:
Total Iloors 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 healing system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage" may be substituted for"Total Project Cost"