3 CAMBRIDGE ST - BPA-11-117 The Commonwealth of Massachusetts
° Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7a'edition ReOF S EM✓
Building Permit Application To Construct, Repair,Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
�\ This Section For Official Use Only ,
�Bdilding Permit Number:- `Date Appli
. n ,
n
Signature:
Building Co iWsiolne�i�Ing�ectorofBuilddmgs ,A ,c Date' _ -
SECTION 1�SITE`INPORMATION',` , .
1.1 Pr erty Address: i 1.2 Assessors Map&Parcel Numbers
L la Is this an accepted street?y _ 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 OWNERSHIPt'
2.1 Owners of Record: C,- L
Name(Print) Address for Service:
;? s�- zy,
Signa ure Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units - Other ❑ Specify:
Brief Description of ProposedWork2: -y-
SECTION 4: ESTIMATED'CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials a
1.Building $ 1. Building n Peiiit Fee. $ Indicate how fee is determined:
2.Electrical $ ❑Standard 'City/Town Application Fee
❑Total,Pro38ct Costa(Item 6)x jnultiplier x
3.Plumbing $ 2..Other Fees:
4.Mechanical (HVAC) $ List: -
5.Mechanical (Fire
Suppression) $ Total.All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ❑Paid i g
n Full'_ ❑,Outstandin Balance Due:
/"� _
`'" r .SECTIONS ,CONSTRUCTION SERVICES,
5.1 Licensed Construction Supervisor(CSL)
M (Cl a if L f 6i License Number Expiration Date
Name of CSL-Holder List CSL Type(see below) y
A'd-E' Vt 1`i.y Uy J A U`e J S'
Address( `si. •' ;:D'ekri tion
12, • � ����,� Q / I! _ U Unrestricted(up to 35,000 Cu.Ft.
R Restricted I&2 Family Dwelling
Signature �, / M Mason Only '
Z- —7 4'S 9313 RC Residential Roofing Covering
Telephone WS Residential Window and Siding
_ SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Re,'Ste-el.. to I provement Contractor(HIC)
Le. -f
HIC Co?9an Name or C Reg tt me Registration Number _
Address. _ 7 -,1 51-7/Q
Expiration 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:R , . NTROWNERAUTHORIZATIONVTO BE,CbMPLETEI)WHENt:,
OWNE 'S AGENT.OR C ACTOR�APPLIES FO BUILDING PERMIT
& f2/ O as Owner of the subject property hereby
authorize I to act on my behalf,in all matters
relative to work authorized by this building permit application.
12
Si nal=ofOwner - Date
SEC TION7b:O9WNER'sOR: .UT$ORIZ,ED.AGENTDE_ LARATION
as Owner or Authorized Agent hereby declare
that the statements and informatio on the foregoing application are true and accurate,to the best of my knowledge and
behalf
t� l
Print Name
Signature of Owner or Authorized Agtnt Date
Si ned under the pains and penalties ofperjury)
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an utuegistered 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 780 CMR Regulations I IO.R6 and I MR5,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.) 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"maybe substituted for"Total Project Cost"