0008 CASTLE RD - BPA-11-844 a
The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY M
Massachusetts State Building Code,780 CMR Sd Mar
Revised Mar 2011
Building Permit Application To Construct,Repa' , Renovate Or Demolish a
One- r Two-Family elling
This ection For O Icial Use Only
Building Permit Number: / ate Applied: c r
Building Official(Print Name). V Signata . - Date `
SE TI N 1: SITE INFORMATION -
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
g�Lb s%A- it o
Lla Is this an accepted street?yes i,-�no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(11)
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:
Publi Private❑ Zone: — Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 O nertof Record:
Crta �'1� YJ�Sri i���o Gam-R� S olrs, I7o o�r xi
iame(Print) City,State,ZIP
,?� co
No.and Street o Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied NY" Repairs(s) ❑ Alteration(s) X Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': <.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ !> 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ �'/,>-'�.� ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ ,..i��xJ.�f�
/ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) '—' Total All Fees:
v:- Check No. Check A u, : Cash Amount:
6.Total Project Cost: $ aPt-M,.e,-� ❑Paid in Full ❑ Outstanding Balance Due: /
15�6 r 1 1�-P M � �-
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction.Supervisor License(CSL) 35 3 U
�1 Cs y i 2-z-Z01 L
P4gyJtP �Mb1QH License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Stree-11t� Type �: Description
�f GAO /VW ULS(�� U Unrestricted(Buildings u to 35,000 cu.ft.)
`� R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
5 7�1/'7 y<-'3�4% I Insulation -
Tele hone Email address D Demolition
2 Registered Home Improvement Contractor(HIC) 'Y�3 7 5 7J
v A F'P1M1J l� 404-W 60VT 22'' n C HIC Registration Number xpir�� ration Date
Hf ompa�J3'Name or HIC gistran e U
+-;6 I
No.and Street Email address
S"(oy, ✓we
City/Town,State,ZIP 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:OWNRICAUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize Rocltr t JCT-ey"1)IC tom"
to act on my behalf,in all matters relative to work authorizell by this building pelmit application. C ,'
Print Owner's Name(Electronic Signature) Date
SECTION 7b:.OW ERA OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
5- ZS- fJ
-Prh*-Q4m 1s-"Author' ed Agent's Name(Electronic Signature) Date
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 can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dus
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable roomcount
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 be substituted for"Total Project Cost"