38 COLUMBUS AVE - BUILDING PERMIT APP 4 L
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
1 M CIR Massachusetts State Building Code, 780 SALE�I
Revised filar 2011 �
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Usa Only. '
Building Permit Number. Date Applied:, " ) 2—a "
Building Official(Print Name) Sign Date
SECTION I:SITE INFORNWTION
1.1 Pro erty Address: 1.2 Assessors hlap& Parcel Numbers
3� C r� Lv.,-.-6vs f-tci-P _
1.1 a Is this an accepted street? yes_ no Ivfap Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.01 c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2:; PAOPERTY'OWNERSHIPL
2.11 r Owne /of Recor�'t`
R. i-. (11 1.662
Name(Print) City,State,ZIP-
38
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK°'(check all that apply)
ENonstruction❑ Existing Build' Owner-Occupied epairs(s) Alteration(s) ❑ Addition ❑
ition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
escription of Proposed 1Vorkr: P.� As o+s—
R I G h a S'�y18 I'� F ✓��'r.�'1^ fs-Cst1�J `� '� A
SECTION 4: ESTUNL41ED CONSTRUCTION COSTS-
Estimated Costs:
trem Official Use Only
Labor and Nfaterials
1. Building $ y qS 00 I. Building Permit Fee S Indicate how fee is determined:
2. Electrical $ ❑Standard.City/Town Application Fee
❑Total Project Cost (Item 6)s multiplier x
3. Plumbing S 2_ Other Fees:'S
t, Mechanical (IIV.AC) S List:
5. %lechanical Giro S
Sii essi m) _ Total All Fees:.S_
Check No. -_ Chcck Anwunt: __ Cash \nwnnC
n l'otul Project C'ust: S. (/ LA
i b 5 00 ❑ P ud in Full ❑ Outslvulin; I1 iFtnce Dui,
p/1/�iL -10 C0QT(2F0tor�
a -
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) t� �- 16 _ S�� _ kk
. M .��,12s License Number Expiration Date
Name of CSL I folder
n List CSL Type(see below)
3 fR .y C t�/'�—P S l MUUnrcstricted
Description
No. and Street
Duildin s u to 3i,000 cu. ft.— �f� � k -R 6 8 Restricted 13t2 Famll DwellinCity/Town, State,ZIP %lasonrRootin CoverinWindow and SidinSolid Fuel Burning AppliancesnsulationTale hone Email address Demolition
5.2 Registered Home Improvement Contractor(HIC) C) 1 l —�3—I Q
LA-,.0 n 1.b..-o1� C�/ A-z:;7- HIC Registration Number Expiration Date
I IIC Company Name or IIIC Registrant Name
2-3 a U." �c
N�Street Email address
-�P.46 cr AoIe,4e,-p - s3 [�a3
City/Town,State, LIP 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 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
to act on my behalf, in all natters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7h: OWNER' OR AUTIIOR[ZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's o Aut rind: ;el ' Name(Electronic Signature) Date
NOTES:
I. ;1n Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the [ionic Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at
www.mass.t ov bca Information on the Construction Supervisor License can be found at www.nass.g jLdLI 2
2. When substantial work is planned,provide the information below:
Turd floor area(sq. R.) (including garage, finished basement/attics, decks or porch)
Grosi livin.,:Ilea(sq. d) -- — Habitable room count
Mimberoftireplaccs_--__----- _ Number of bedrooms
-----------------------
Number of bathrooms Number of haltrb.uhs
fvpe Uf IK:I(Illg sySICIII . ,_ ___ -_--____ Nlllllbdf Uf deCkii pOl'iheS
I\pc of cooling cy;tcin Enclosed Opcn
� 1 I,ILII I'roj:it Syulro Piat.lyc" ul.ly he ;ub;tihit:d ter 'f„t.11 I'rujcct (_o;t"_ _ -----