3 CAMBRIDGE ST - BPA-2010-07 a4,p
0 "Permil
The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7'"edition Building Depi
Permit Application To C t, Repair. Renovate Or Demolish a ! 8►One- tco-Fmni •Dnrlling
This Sec n For f iicial Use Only r Applied:
ture: I G
Building Commisst ner/inspectoro ' rigs Date
SECT : SITE INFORMATION
1.1 Properly Address: 1.2 Assessors Map At Parcel Numbers
�te/'I o- t i
I.la Is this an accepted street?yes�o Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning Distnct Proposed Use Lot Area(sq B) Frontage(a)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
[PI,
6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
blic❑ Private ❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check it yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Le✓�zl��
Name(Print) /�JqJ., , Address for Service: _
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ Repairs(s) O Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
• G tiG rn
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing f 2. Other Fees: S
4. .Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees: f
Su ression
Check No. _Check Amount: Cash Amount:
6. Total Project Cost: S �r✓ 0 Paid in Full 0 Outstanding Balance Dur
SECTION 5: CONSTRUCTION SERVICES
.1 Licensed Constructlon Supervi r(CSL)
5 )
'' ena— License Number Esp r do Date
N.4mc ul'CSL-Hplder / List CSL Type(we below)
GL L/
Type I Description
Ad r s
1-(J-J I Unrestricted Jup to 35,000 Cu. Ft.)
Signature
R I Restricted 1&2 Family Dwelling
M Masonry Only
y��2 6�:i :2 RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered ,o711rnproyjment Contractor(HIC)
pa rx .0 '
HIC Company ame or HIC egistra ti N e Registration Number.
Addrep.
C =) Ea iration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.f 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 CONTRACTOR APPLIES FO BUILDING PERMIT
1, t ro d as Owner of the subject property hereby
authorize 4e-- to act on my behalf,in all matters
relative to work authorized by this uildi g errnit application.
Si 08tuR Of Owner Date
SECTION 7b:OWN Rt OR AUTHORIZED AGENT DECLARATION
-el , � ,as Owner or Authorized Agent hereby declare
that the statements and inf ation on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name
6 � a
Signs re of Owner or ulhorized Agent Date
Si tied under the sins and enalties of ru
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. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and I 1O.R5, respectively.
When substantial work is planned,provide the information below:
tal floors area(Sq. Ft.) (including garage, finished basement/attics, decks or porch)
oss 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"may he substituted for 'Total Project Cost"