2 CHAMPLAIN RD - BPA �D
Q The Commonwealth of Massachusetts Town of
Board of Budding Regulations and Standards loomeow
Vlassachusetta Stale Building Code, 780 CMR, Pa edition Budding Dept
Building Permit Application To Construct, Repair. Renovate Or Demolish a fWomldvm
doom
One-up rrru•Faindr'Du effrng
This Scgri-ok For Official U nl
Building Permit Nu r: Date A .ed:
Signature: ?) l�
Building Commissioner/Inspator of Burldt gs Date
SECTIOJr:SITE INFORMATION
1.1 Paper �ddreu: �� 1.2 Assessors Map S Parcel Numbers
oL C ha.nlJ�ain /�
1.1 a Is this an ace teal street?yrs no Map Numbs Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Fromage(A)
1.5 Building Setbacks(R)
From Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c.40,154) 1.7 Flood Zoo*Information: 1.2 Sewsga Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Public O Private O Check if s0
SECTION 2: PROPERTY OWNERSHIP'
2.1 fin«'of Retord:
��la-c✓i`
NIUMA nt) Address for Service:
Si lure Telephone
SECTION l: DESCRIPTION OF PROPOSED WORKS(check oil that apply)
New Construction O Existing Building O Owner-Occupied O Repsirs(s) O Alteration(s) O Addition O
Demolition O I Accessory Bldg. O Number of UniU_ Other O Specifry:
Brief Description of Proposed Work':
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costa: OMCI&I Use Only
Item Labor and Materials
I. Budding S 1. Building Permit Fee: S Indicate how fee is determined:
O Standard Ciry/Town Application Fee
2 Electrical S O Total Project Cost'(Item 6)a multiplier a
Plumbing S 2. Other Fea: S
a. Mechanical (HVAC) S List:
S Mechanical (Fire S Total All Fees: S
Su ression
rQ Check No. _Check Amount: Cash Amount:_
6 Total Project Cost 0 Pad in Full O Ouwanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
S.I Licensed Construction Supervisor ICSL)
r, 7v G7 L�
License Number E.puu ion Date
N..#w ol'CSL. IylJer /
List CSL Type(see hclow)
AJbesf /�7e6l 1 Tvos 1Description
U Unrestricted(up to 37.000 Cu. Ft
R Restricted 161 Family D%cllin
M Masonry Only
RC Residential litooling Covering
Telephone wS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D 1 Residential Demolition
5.2 qe syredH� It vemeatContractor(HIC) �� J9���
HIC Compan Nam r egrstiant Name r Regtsuation Number
'�
A .� 9sg3ss�
.� Expiration Due
Sisnanue Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.1_e. IS2.1 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 of the building permit.
Signed Affidavit Attached? Yes..........O No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize &Znq to act on my behalf,in all matters
relative to ork authorized by thiss�ls�uilld�ding permit application.
Si a off Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
I, �`�� � `/ �!✓�'h dlels ?;�IG , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
CL`�h h
Prim 3�3 to
Signature of Owner or Authorized Agent Dale
Sr iced under the pi and penalties of
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 Rg have access to the arbitration
program or guaranty fund under M.G.L. c. I41A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110 R6 and I WAS,respectively.
2. When substamial work is planned,provide the information below:
Total Doors area(SQ. R.) (including garage, finished basemenVanics,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 hearing system Number of decks/porches
Typeof cooling system Enclosed Open
1 "Tool Pro)ect Square Footage'may he suhsntwed for-'Total Proleci Cost'