4 CHAMPLAIN RD - BPA (002) The Comilt+anecalth of Mas.achusctls I t ilt
t` lir+urd of Building RrL:ulanon, and S(andaids \II NIO II' \III 1
f� \ y \ta..,tchusrus State Building Code. 7SU( MR. 7"' culition �I
Building Pennil :\pPlicuticm Ttt (lmatnlrl. Repair. Rcnot.tte ()I I eMoli,lt a
H: ,l lur.nn r
Obtr- err Tu a-l' unil c Du rllin�
\-� - Thu Beacon For
\Vn� _-_ OYfi l'se Unly
BuIIJIn_ Prnul Nun er l:ur Applied:
r
Budd:uf (\nlmu.,ion. / lu.l.ril+v ul Buddiop, Dale
---- - SEC"I'ION 1: SFFF' INFORSLA'I'ION
-LI Property Address '''�77 i 12 Assessors Map S Parcel Numbers
CNA/" PZ-
q Numh,'. I .u. I Nwnh.r
xcepleJ ,u'te r. sr, u+..._. _ .
Information: I 1.4 Property Dimensions:
:ofi.F:C Dl%trlet---...— Pro Dr,rd Use — 1 LUI AILZI I,l{ 11) Fit"Ita_" III
1..5 Building Setbacks (ft) _
From Yard
.Side Yards Rear Y aid
RrgwrrJ I Provided Reyuurd PPnnided Rryuu rJ I'n:+iJrJ—�I
7 G 7,iar 5cp�ly: LN.QL e. 10, §511 1.7 Fl+w n d Znc lrformation: 1.8 Sewage Disposal System:
Zone. _ Quts:u-e F!:wd Zone" ( Municipal ❑ Qn ,ne di,p Kcal ,"rein O
Public C- Posate ❑ Check it ye,
--- - — - - _—SE.CT"oNz: PROPERTY OWNERSHIP'
2.1 R�Recor ---
-, Address lur Service' _—
um• rt ri no R—3
i 9� i _3Da-D _ ----- - I
.,In ur - Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Coro;ruction ❑ Existing Bwlding O LC.ttr.erOccupied ❑ I F:ep:w�ls1 O Iteratu,ni o) O r\JJiw:n ❑
---
' Number otr UniltJther ❑ Spear -
E Demoi n ❑ Arcess ny LIJg ❑ _ --(,----
_ M r r
/{l'Ict " on :f Proposed Wufk'
ig.— P.'.�i..ra—Jeyr
Dlxner
"X
SECTION 4: ESI_JM A :ED CONSTRUC'TIC:: COSTS
I
' Estimated Cants: I
j Ilnm tl.ahor:md "`I:mi,,tIs)
�_ Official Use Only _-_--- .--__---_--- I
I Building S I I. Building Permit Fee: S___"_ Indicate hnss lee i, Jari nu neJ:
❑ Standard CaylFuwn .\ppbcanun Fee
? Electncal S
O"renal Project Cost 1 Lem G1 x multiplier
1. I'lumhin¢ "•' _'. Other Fees: S -
1. :\leehamcal IBA':\C1 5 Liar_ _..-- ---
i Slec tamed lFlre S fn6il :\II Fee,: - --" -_- -
Su t,res,nmi ---_y Check No ___-O'heck Aimiunt _----1 '.i,h \nb:unl
�b rolal Project CusC 7 p_ • "�' ❑ Paid III Full OO)uist.olding R.iLune Itur---- _ -
-e
SECTION 5: CONSTRUCI-ION SER'll
';.I
y,
\jilic It t SI, I I"I&I I "I C S L I,I Ile I'C' h6lo,I
R I N ......1, 1),
"l-Ill.itile ,, � %I,mIr\ Ork -I?i:-j,ntIj1 koofmc ( 'I,.,I'll-
I'll"lle
Rcld'.111,1
5.2 Registered I Irarm I unpro cement Contractor I I I I C I
III(' Coull'.11IN N'llic or IIIC RCgJ,oallt Naille
Signature I cle III Io Ile
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT 1,M.G.L. c. 152. § 2506))
)rkers Compensation Insurance atfirda,lit must be c,,rnpleted illd 11.1holitted `,kith IhIN APPI11AI-I'll 17.111LIle 111 1)
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes - ..... 11 No 0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT,OR CONTRACTOR ""PPLIES FOR BUILDING PERMIT
I 1, \1 +4" as Owner of th• ,,,hj,:ri po,pcit,, hereby
I all i I,I e to aLl Ilo 1111 I'LILdf. 11- il: ll)lit[Cln
2.Al l.c to •Aorkauth r:z . f filing pernnitapplil:anon.
Siclia 4 111 ),,llner Da',
[ON 7h: OWNEWOR AUTHORIZED AG ENT DECLARATION
is Owner orAuthm t/ed \,-ent heich) J"Loc
[that the statements and infiorria(ionon the toregoinc application arc true and accurate, to the best or my kroo,licdize and
behalf.
Prior Name
Siviatureol Owner or Afflhoo/ed ,Ageru Dale
s4med under the pains and penalties of perjury
NOTES:
I. In O% n erlhoo rai ns d huIdnpemo, ,o do hu/her r '-n Iranoo,,,seer h hues
on'eL"'Zo " 'oI""' ILI"I
flume
lnpo, neII Contractor
fUT Program
I will
"Ih,' I'll1II , the , m l m
program
orar"j, fund under m � I , 142A )Iherr," tiol "to 'II, onth IIIIprolonld
\Ahen uhmanlial lIorl, is planned. pmo%ide the Information below
[,,(if tlo(Irs area ,Sy. Ft.I iincluding garage, tim.,hed
(o,I,sIo,n,, aieilSq H,ihrahIeil,,lrn ,,unt
Number t nrcplaces Noinher ,-f hedro,in,
Vinihei ,I hathto,lms Nullihcr ,1 1%11:
Number I�t J"k,/ p,-I hc,
shy
Pr,ject SLlu.re III'I!, he 'uh,titued f;IF FI IL'I I'll-le,I C, I**