41 COLUMBUS AVE - BUILDING PERMIT APP (002) The Commonwealth of Nfassachuselts
1 -7,
Board of Building Regulations and Standards CCCY OF
Massachusetts State Building Code, 780 C vlR Sd Mar
A
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dtivelling
rhis Section FOrOfflet Usa0nI
Building Permit Number: Date Ap lied;
Building Official(Print Name) Sig c ata
SECTION L SITE INFORbGWTIO
Pro erty Address: L2 Assessors Map& Parcel Numbers
pit l �ol urvt Btls /� A/U
1.l a is this an accepted street?yes v no Map 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.G.L 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 i; PROPERTY WNERSHIP
r� goe(P
avner'ofRecord: /�� `yy� OL497)Cd�/
/t) City,State IP
uM "Aw c o a
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other O Specify:
Brief Description of Proposed Works: z_,- 7kz�0C9!4a
4!��L t±XCA lYi
SECTION4: ESTINLATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only.
Labor and Materials)
1. Building S 1. Building Permit Fee.,S _ rndicate how fee is determined:
Cj Standard.Cityfrown Application Fee
3. Plumbin;. F,lectin $ ❑'CotalProjectCost'(Item.6)xmultiplier x
S 2. Other Fees: .S
t. Mechanical (llv.w) S List'.
i. %lech:utic'it (Firo S
Snp iressioli) ['otal All Fees: .S-
- Check No. _ Chcck Aumunt:. _--cash \mount.
�; -1'ut:tl Project Cost: 3 - UV ❑ Riid in Full ElOutstandm" 13 tllnco Du .
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 1
License Number Gxpimttion Date
Name of CSL I[older List CSL'Type(see below)
Type Description
No. and Street
U Unrestricted �uildin s u to 3i,000 cu. ft.
R Restricted 1&2 Famit Dwellin
City/Town, State, ZIP bl D-lasonr
RC Rootin Covcrin
WS Window and Sidin,
SF Solid Fuel [laming Appliances
II Insulation
1'ela hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I I[C Company Name or 111C Registrant Nome
No. and Street Email address
City/Town, State, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 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 matters relative to work authorized by this building permit application.
Print owner's Name(Electronic Signature) Dnte
=- %v
ECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
below, I hereby attest under the pains and penalties of perjury that all of the information
ication is true and ccurate to the best of my knowledge and understanding.
"It's Name(Electronic Signature) Date
NOTES:
I. :\n Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not regi listered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty nd under M.G.L. c. 142A. Other important information on the 1-11C Program can be found at
www nM5:."ov ora Information on the Construction Supervisor License can be found at uewvw.mass.au�dL:,
2. When substantial work is planned, provide the information below:
Total floor area(sy. 1t.) _(including garage, finished basement/attics, decks or porch)
tlro;i living urea(.iy. tt.l _ _ habitable room count _
Nurnbcr of tiraplaces. ---__-- -- `'umber of bedrooms —
-_--
Munberofbadirooms __ Numberofhalt'baths _-- —
1'vpe oFhe.ttiug Systems _ _ _— -- Number of,lack 'Porches ---.. ----- —__--
I)peofcanlingSy;tcitt Enclosed . . Upcn
4. `1luial I'r„ .et s,I u:u Pant u e may he inbifitut I L+i I ,:.ul I loicet Coo„
I