8 BURNSIDE ST - BPA-12-309 1
fhe C'urnnwmvealth of Massachusetts — - --
1 hoard of Building Regulations and Standards CI I'Y OF
Massachusetts State Building Code. 780 CMR SA L LA I
i3ttilding Permit Application -ro Construct, Repair, Renovate O olish a
One-or Tmvr-Faniil.v Du L41ml,r J
This Section For Officia se Ot�l
Building Permit Number: Date; pplied:
Ihulding Ullicial(Print Mane) Signatured )ale
SECTION 1:SITE INFORN[ATION
1.1 Property Add r �,, 1.2 Assessor bla P eel Number
I.to Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Tuning District Fr puscd Use Lot Area(sq It) Frontage(tl)
1.5 Building Setbacks(R)
From Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if --1 Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
Name(Pont � Uq.State,LIP
Nu.and Strcot �3f0e hone
P Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all t I apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specit'y:
Brief Description of Proposed Work :
SECTION 4: ESTINIATED CONSTRUCTION C STS
Item Estimated Costs:
(Labor and Materials) Official Us Only
I. Building _ S I. Building Permit Fee: S Indicate how fee is determined:
'. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier _ x
1. Plumbing S _1. Other Other Fees: S
4. Mechanical ill\':\CI S List:_
5. \fech;utical (Fire ._ --- --_- ----- --..
Su„ressioni S 'rural :\Il Fees: S_ _
e. Total Projcct Cost: ) Chcck No. __—('beck Amotmt: -
❑Paid in Full ❑Outstanding Bahmce Due:
t�
SECTION 5: CONS'I'RUC'rION SERVICES
5.1 Construe ' u Supervisor •Ilse(CSIL
--1-s -F'--- --
I.Icensu Numhcr P\pir; ion )ate
-+ List(.'St.1)pe(see hVitn"
_ IIL•L 'I''PC Dascripliun
No. ;u1 Street
ll Unreslriaed(Ouildin gs ti to)5.u1)O cu. ILI
_ It Restricted I&2 I�aulil lJocllin
Citvi, on State .I - - ---- NI -0asonry
RC Roofing C'overin
W S Window and Sidin
r SF Solid Fuel Iluming Appliances
935 ar�� I Itsulmion
'I elctillonc Email address D Demolition
5.2 Registeredllom g1lo,tic tor(HI hs stir eW eI 'rYr>' rttsN',�lie or I IIC' INu. and tr ut limail address
City/Town,State,ZIP etc hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.! 2SC(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 oft wilding permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 79: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize age
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Nanle(Electronic Signature) Date
SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the ' s and penal ' of perjury that all of the information
contai this application is true and accurate to t e b t of y k led and understanding.
VW
Prim Olcncr s or:\uthur�Agem s Nmnc IP.Icctrooic.Sigoa re) D'
OTES:
I. An Owner who obtains a building permit to do his,her own work,or an owner who hires an wtrcgistered contmctur
(nut registered in the Hone Improvement Contractor(HIC) Programl,will no have access to the arbitration
program or guaranty tund under \I.G.L.c. 1 J2A. Other important information on the HIC Program can be hound at
1u\\\ ) .l.. ok..1 Information on the Construction Supervisor License can be found at t\>r n,ma,;:�o\ ,111,.
2. When substantial work is planned, pro\ide the information below:
Total fluor area(sq. ft.) _ ____-__(including garage, finished bascnnenL'mtics,decks or porch)
Gross living area 1 sq. It.) Habitable room count _
Number of fireplaces_— Number ul'bedruunu
Numberot'l+athrocons _ \umbcrol'halfhatlu
I\pc of heating s)slcm . . ._ Number of decks, porches
I\lie al'C0u111115\i(Ctn _ - I,Ilcloicd _ . . _t)pen
}. "total Project Square Foolagc" Ilia) he\nbStllmed for"folal Project Cost'
I