0006 CHERYL AVE - BPA-08-1022 The Commonwealth of Massachusetts
► Board of Building Regulations and Standards I OR
m Ml'Nltll .\Lfl l
E. 'A � Massachusetts State BuildingCode. 780 CMR. 7 edition
� W l!tiF
t� Building Permit Application To Construct. Repair. Renoaate Or Demolish a Reri+ 'i l:uro:u+
One- or T(ro-Family Dv;elling 1 'i to"
l _ This Section For Official Use Unly
Building Permit Number: Date Applied:
\� Signature: �'�^ L
Budding Commissioner/ Inspeaur ut Buildings Date
SECTION I: SITE INFORMATION
1.1 Property Address: �^ ^/ f- ^ ^ �� 1.2 Assessors !11up & Parcel :Numbers i
I.la Is (his an accepted street'? yes— 1 no T Map Number Pancl Numbrr
1.3 Zoning Information: 1.4 Property Dimensions: -
Zoning District Proposed Use Lot Area(sq A) Frontage(it)
WSupply:
acks(ft)
Yard Side Yards Rear Yard
Provided Required Provided Required Provided
(M G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
e❑ Check if yesr3 Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 OwnertofRcC rid J �6/ 6, Clcv,/4'�
_,_
Name(Print) / Address for Service:
Signature- Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'check all that apply)
New Construction. Existing Building ❑ Owner-Occupied ❑ 1 Repairs(,) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify:
kBriefsc�tion of Proposed Work :
/CA-✓ �}lc./,i FieSECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ y0 G -�- 1. Building Permit Fee: $ Indicate how tee is determined:
❑ Standard City/Town Application Fee
2. Electrical S ❑Total Project Cosh((ten 6) x multiplier x
d. Plumbing $ 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire $
Suppression) Total All Fees: S
pJ Check No. Check Amount: Cash :\mount:
6. Total Project Cost: S y p 9 0 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL)
License Number F:xpoau on Dale
Name of CSL- Holder List CSL Type isee helow)
T pe Descri nun
Address L Unrestricted (up to 3SSW Cu. Ft.i
R Restricted 1&2 Family Dssellin
Signature .M slasonry Only
RC Rhidennal Rtwlin Coverin
Telephone w'S Residcnual tivindo, ind Sidin
SF ResiJcnual Solid Fuel Uunune :\r iham.• bt.i.J l�wm
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Nitric or HIC Registrant Name Registration Numlxr
Address Expiration Date '
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. S 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure it, pnwide
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
� as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to w rk authorized by this ilding permit application.
Si nature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I , 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.
Print Nano
Signature of Owner or Authorized Agent - Date
(Signed under the pains and penalties of ru )
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 not have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. 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 busemenUattics.decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of h uhrooms Number of halt/baths —
Type of heating system Number of decks/ porches
Type of cowling system Enclosed Open j
3. 'Total Project Square Ftwtage" may be substituted for"Total Project Cost"