7 CHAMPLAIN RD - BPA 1'heConunonss'ralthoFMassachusctts __
Board of Buildin 6 Regulations and Standards CITY OF
g
M:ISSaI'I1u5CIt5 State building Code, 730 CM l:�\t
l i.ved fa _'Bll
Building Permit Application To Construct, Repair, Renovat L nil h a
One- or Two-Fumi(r Dwvllhnq
This Section For Official Use only
Building Permit Number: _ Date pplic
lhiWing Olticial(Print Nmne) Sit urc ( to
SECTION 1:SITE FORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
I.la Is this an accepted street?yes no Map Nwnher Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Lulling District Proposed Use Lot Area(sy It) Fmnlage 111)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Private❑ Zone: _ Outside Flood Zone?
rh_G;r...kwMunicipa '2 On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
- 2.1 Owner'of Record:
1 a44. ,��E t FIPQ l t , Trt.(.S-t Ste, le t o �I/4 o 19 J y
N;une(Print) / city,State.ZIP
0 e. 6elkwsC1,r•cle- e -? 'ts-3535-
Nu.and Street Telephone Finail Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) * Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work'• 'Z.Q C3'-'`
F
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofllclal Use Only
(Labor and \Iaterialsl y
I. Building S ')-J"Zu 1. Building Permit Fee: E Indicate how fee is determined:
2. lilccirical g ❑Standard City/Town Application Fee
❑Total Project Cost'(item 6)x multiplier ___x
7. Plumbing S 1._. Other Fans: E
4. \leclumical (11\':\(') S List:
--------------- --
' S. .\Icehmticel (Fire S
tiu+ttcssionl Total :\Il Fees: S
(1. Total Project Cost: S r1a "? Check No, __—Check Amount: _ ---- C';uh Amount:
❑PniJ in Full Uutsumding Balance Due:
r 7
SECTION 5: CONSfRUCT1ON SERVICES
5.1 C'onstructionSupervisurLicense(C'SL) 77SL `�1d13
. TAG"
I.ictnse Number Pcplrallon l7ata
N;unc ul'C'SI. I Inlder
List C'S1,l)P°Isee heluwl�-_____
IMP, Description
and Street
U (Inrcitrieted I IIuilJin o 0 to 19,0110 eu. It.)
R Rearicted NIL,I Family Dlldlin&
C II\'i fuen,state./IP M Masonry
RC Rooting Coverin
.__. W'S Window;md Siding
SF Solid Fuel Iluming Appliances
•� �r4 r O- 7 I Insulation
'I'ele hone li... . a rya r D Demolition
5.2 Registered Home Improvement Contractor(HIC) (06t'U6 � 3 2
s
��� �,..et,� �t - IIIC Registration Number lispirnlion Dale
IIIC Company it nr I I !'Registrant Nmne
No.and Street Email address
City/Town,State,ZIP 7elc hone
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 Affidavit Attached? Yes ..........� No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize 1'1faAX i A/r t L
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(ElectronicSignature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contain in this application is true and accur2WyC#SQ
ow) a and understanding.
�U `TA' /0 TV/ /
Prim Olt ner's ar:\uthurired A cnt's Nettle I I.kctnn r• g , ure) Date
NOTES:
1. An Owner who obtains a building permit to do his,her own work,or an owner who hires an unregistered contractor
(rest registered in the Hume Improvement Contractor(HIC) Program), will no have access to the arbitration
program or guaranty fund under I.G.L.c. 1 a_'A.Other important information on the HIC Program can be found at
lll„1 nl.r.. „1 ,I..r Information on the Construction Supervisor License can be found at„\s,l nlas? •.,A It),
\?'hen substantial work is planned, provide the information below:
Total lluor area(sq. R.) _ __--_(including garage, finished basement attics,decks or porch)
Gross living area Isy. III.) _.- habitable room count
\umber of fireplaces Number of bedrooms
I)pe of heating system _ Number of decks, porches _
I I1pe "(1:0011ngs�stein 1�I1eloscd (Ipell _ -
1. "Tonal Proicct Square FoolagC" i»ay he Substituted Ilor"I'olal Project Cost"
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