11 BRYANT ST - BPA-11-738 h
The Commonwealth of Massachusetts La /.
Board of Building Regulations and Standards
i Massachusetts State Building Code, 780 CMR, 7ih editionEM
I I - twry
Building Permit Application To Construct, Repair, enovate Or Demolish
/I One-ur )-Fmni.v Dwel!rig
s Sec iun For OfficA Use Only
Building Permit Number: Da Applied:
Signature: '
Building Commission /I •tor of do Date
SEC I 1:SITE INFORMATION
1.1 Property Address: V 1.2 Assessors Map& Parcel Numbers
I.la 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(sy m) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Reyuircd Provided Required Prov,&d Required Provided
1.6 Water Supply:(M.G.L c. 00,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑ p p y
SECTION 2: PROPERTY OWNERSHIP'
2�l lgwner of Record'
� ' �Y
N me,(P,tint) ^ Address for Service:
V7414 e
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work'-: 4
W LN I!
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I. Building S I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost (Item 6)x multiplier x
3. plumbing S 2. Other Fees: S
4. Mechanical (IiVAC) S List: ��
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No._Check Amount: Cash Amount:
6.Total Project Cost: S /-700 13 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) / p 2-49-7 57V e/
RrefF,� License Numher Espi at'on Date
Nan C0 J�/ttA I I I �P_ List CSL-type Isce below)
J ( " -FN PC Description
Address
I1 I htrestricteJ u to 15,000 Cu.Ft.
R RestricteJ I&2 Fumil Dwellin
Signatur M %lasonry Only
RC Residemial Ruotin Curerin
Telephone WS Residential Window and Siding
I �0 7Y/ Y7) SF Residential Solid Fuel Burning Appliance Installation
o D Residential Demolition
5.2
,j is egistered Home Improm veent Contractor(HIC)
wt r'-II� t
I IC Company Name or HIC 12egislrant Nate Registration Number
Address
_�l1CF� Lxpfmtiob Date
Signature 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 .......... ❑ No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONT CTOR APPLIES FOR BUILDING PERMIT
11 Gir Op4 /5 CPe , as Owner of the subject property hereby
authorize 4q,6MrZ4 /}l"&I 64/13W Gt/' )Ais/CrZyt"� to act on my behalf, in all matters
relative to work authorized bythi building permit application.
Si, ature ot'Owner Date
SECTION
/7b::-O-WNERt OR AUTHORIZED AGENT DECLARATION
I, lG ram" ,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.
Print Name � ,7 (,
Signature orOwner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 7,80 CMR Regulations 110.116 and 110.115, 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.) Ilabitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of hal0baths
Type of heating system -Number of decks/porches
Type of cooling system Enclosed Open
}. "Total Project Square Footage"may he substituted for"Total Project Cost" 16g$.