4 CHAMPLAIN RD - BPA r Q The Commonwealth of Massachusetts Town of
O Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7'"edition
Building Depl
Building Permit Application To Construct, Repair. Renovate Or Demolish a
One- or Tyro-Fumill Duelling
This Section For Official Use Only
Building Permit Num r: Date Applied:
Signature:
Building Commissioner/Inspectorof Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Addrffstess:m�L-t*)� r�� 1.2 Assessors Map& Parcel Numbers
C
1.la Is this an accepted street'!yes l : no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning Distnct Proposed Use Lot Area(sq It) Frontage(it)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.154) 1.7 Flood Zone Information: 1.9 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system Cl
Public O Private O Check if esO P po y
SECTION 2: PROPERTY OWNERSHIP'
Owner'of Recgrd: I ,I L�-y-,�Mp LA, i r`J � r
Name(Prin) rJ nl Address for Service:
q?k - -7 3oZc�
ure Telep one
SEC N l: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction Existing Building O Owner-Occupied ❑ Repairs(s) Alleration(s) O Addition
Demolition Accessory Bldg. O Number of Units_ Other ❑ S city:
Brief Description of Proposed Work=: 1/ ' I V( !� OVA
r
SECTION 4: ESTIMATED CONSTRUCTION COSTS
jT0181
Estimated Costs: Official Use Only
Labor and Materials
ng4COSI:
f 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
calS O Total Project Cost/(Item 6)x multiplier x
ingS 2. Other Fees: f
nicalS Lis
nical
onS Total-0 Fees: S
Check No. _Check Amount: Cash Amount:_
ProjS 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES !
5.1 Licensed Construction Supervisor(CSL)
Liccrtse Number Expiration Date
N,;poe of CSL- liylder
List CSL Type Im lw luwl
L Type I Description
Address
U I Unrestricted 1 up to 35.000 Cu. Ft.
R Restricted I&2 Family Dwelling
Signature .M Masonry Only
RC I Residential Roofing Covering
Telephone r wS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 ARdavil 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 to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: O t OR AUTH RIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
t at I statements and information on th oing application true and accurate,to the best of my knowledge and
half.
Print N r—)
0110 G
of Owner or Authorized Ag Date
Si tied der the sins and penal ofperjury)
NOTES:
I. 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�j 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 l0.R6 and 110 R5, 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 halfbaths
Type of heating system Number of decks/ porches
Type of cooling system Enclosed Open
1. "Total Project Square Footage" may he.uhatuted for 'Total Project Cost"