2 CENTER ST - BPA-13-846 The Commonwealth of\Massachusetts
W Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 730 CMR SdMar
Revised Mar 201!
Building Permit Application To Construct, Repair, Renovate O em lish a
One-or Two-Family Dwelling
'rhis Section For Official Use On
Building Permit Number, Date pile
,S Id
Building Official(Print Name) Signature Date
SECTION I:SITE INFORM ON.
L1 roperty Address: 1.2 Assessors Map& Parcel Numbers
1.1 a 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(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: Lg Sewage Disposal System:
Public❑ - Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesCl
SECTION1:; PROPERTY OWNERSHIP"
Owners of Record: C,\ w �� 6
N c(Print) O tate,ZIP
�E
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WOR.W'(check all that apply)
New Construction❑ Existing Building❑ 0% - ccupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ timber of Units_ I Other ❑ Specify:
Brief Description of Proposed Nork':
SECTION 4: ESTIMATED CONSTRUCTION COSTS-
Rem Estimated Costs: Official Use Only
Labor and Materials
1. Building S I.,Building Permit Fee:S Indicate how fee is determined:.
Standard..Citylrown Application Fee•
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $
I. Mechanical (IIVAC) S List: -
i. ;�faehical (Fire S .
Su > iression) _ _- Total:Ul Fees:.$_
— C heck No. Check Amount: Cash rinwunt:
6 "I'Mal Project Cost: — — -
r Ot�p ❑ Paid in Pull 0 Outstanding 13alancc Duo:
SECTION 5: CONs'rRUCI'ION SERVICE'S
5.1 Construetiun Supervisor License (CSL)
License Number --— Expiration Date
Name ufCSL Ifoldcr
List CSL Type(see below)
Nu. and Street ryPe - Description
U Unrestricted(Buildings up to 35,000 cu. ft.)
R Restricted 19e2 Family Dwelling
City/rown, State,LIP "'-lasonr
RC Rooting Covering
WS Window and Siding
SF Solid Fucl Burning Appliances
[ Inwlation
Nle hunt Email address D Demolition
5.2 Registered Home Improvement Contractor(FIIC)
FIIC Registration Number Expiration Date
I IIC Company Name or IIIC Registrant Name
No.and Street Email address
City/Town, State, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. e. 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 CONTRACTOR APPLIES FOR BUILDING PERMIT
[�P'r-i—ntO%vner's
wner of the subject property,hereby authorize
n my behalf, in all matters relative to work authorized by this building permit application.
Name(Electronic Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By en ring my name below, I hereby attest under the pains and penalties of perjury that all of the in ation
a'ned in this application is true and accurate to the best of my knowledge and understandin .
e t PP
1 2 _
Print Owner's or Authorized A.gent's Name(Electronic Signature) Dane
NOTES:
I. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor(HIC) Program),will root have access to the arbitration
or guaranty fund under M.G.L. c. t42A. Other important information on the FIIC Program can be found at
program g t3
� b round at www.inass�n,v d e;
Supervisor License can e nd _L
ntbam.uuat on the Constructionp
www ni.u-._a ova l
2 When substantial work is planned,provide the information below:
Total flour area(ski. tt.) _ __ _(including garage, finished basemenUattics, decks or porch)
Gross living area(sy, ft.) -_ _— Habitable room Count
Number of fireplace'_ ,--_--_—_-- Number of bedrooms ---_----_--_--
Number of balhromtu _._ Number of halt:baths
----------- -
-
IcpoofheatingsyslCaa _ .._-- Numberofdx 's/porches
I)peorcooling ;y;tent -- -_--- Fticloscd _--- _ _ Upcn -
1. "lot it S(ImIrc Fnnt i,a' ui aY. hL ,iih;tiuit.d toi "I.,[.]I I ioiQct Co;t"