0004 COLUMBUS SQ - BPA-15-773 39 3D
The Commonwealth of Massachusetts RECE D
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BoardofBuildingRegulationsandStandards INSPE TI ES Massachusetts State Building Code„780 CMR U
SE
Building Permit Application To Construct,Repair,Renovate Or DemolisIPJ5 jfteYW4&2g1j
(� One-or Two Family Dwelling
`v I This Section For 2T$Ad Use Only
Building Permit Number: Date Applied-
t� BuildiogOfficialMlatName). 7 signal= Date
SECTION 1:SITE INFORMATION
1.1 Property Ad ess: 1.2 Assessors Map&Parcel Numbers.
S
ILlais this an accepted street?yes! no Map Number Parcel Number
13 Zoning Information:S IA Prope IyDioleasdouse
Zoning District ...Proposed se LotArea(sgft) ..,;:Frontage(ft)
1.5 Building Setbacks(ft)Front Yard Side Yards i. Rear Yard,
Required - Provided Required Provided .Required . Provided
1.6 Water Supply:(M.G3,a.40.§54) 1.7 ftod Zone Information; 1,8 Sewage Disposal System:
Public❑ Private Zone:_ Outside Flood Zone?Check KyeM i MumicipalOOasitedisposaisystem p
SECTION I: PROPERTY OWNERSHIP'
2.1 Oyper'of R A
Name ' t) - - City,State,ZIP -
L1
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WOMO(cheek all that apply)
New Construction 17 Existing Building❑ Owner Occupied p Repahs(s) ❑ Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg.❑ ` NunrberofUnits Other Specify
BriefDescriptlon ofProposed Works
SECTION 4:ESTIMATED CONSTRUCTION COSTS -
Item gdo Costs: i "Official Use Only
1.Budding $ j 1102 3. 1. Building PermitFee:S. Indicate how fee is determined:
2.Electrical $ ❑Standard Cily/fown Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) .$. List:
5.Mechanical (Fire
suppression) $ Total All Fees:$ -
6.Total Project Cost $I-f3 ,SL3, Check No.!I a34Check Amount: Cash Amount.
❑Paid in Full ! ❑Outstanding Balance Due:
Mf-), x LCj � 11( 3 r�5
SECTION 5 CONSTRUCTION SERVICES
51 Construction Supervisor License(CSL) i <y 73
a 3
11censeNumber ExpitationDate
Name of CSL Bolder
List.CSL Type(see below)�c
Eric W.Palm
No.md sweat 3 Hilton Street .f TYPe - Desiaiption
U Unrestricted to 35,000 cu.ft.)
CalemMA '1107(1 R lieshictedl&2Famil Dwellin
Ctty/fown,State,ZIP M Masoury
RC lboafing Covering
WS Wmdow and Siding
SF Solid Fuel BmningAppliances
` O a I Insulation
Telephone fimailad4— D - Demolition
5.2 Registered Home Improvement Contractor(HIC) l o�Q 3 Z (p
Atlantic Weattion4ativii,L,..
HICRc&.trah um
ber mber . Expiration Date
HICCompaoyNameorHI Vetllle -No.and Sheet lem MA Email address -
City/town,State.ZIP .. . Telephone -
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(ALG.L c.152.§25C(6))
Workers Compensation Insurance affidavit must'
ust be completed and submitted with this application Failure toprovide
this affidavit will result in the denial ofthe lssuance a building pert
Signed AffidavitAttached? Yes....,..... No...........El
SECTION 7s:OWNERAUTHOR17ATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOf�RBUII DING PERMIT
I,as Owner of the subject property,hereby authorize
to act on eham inn all matter relative to woorrk authorized by this building permit application.
C�itJ �tifJafl/l� 7 Z
Print O sNam PectromeSigoature) j Date_
SECTION 7W.OWNER!OR AUTHORIZED AGENT DECLARATION
By enterirgmy name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in . appli nis accurate to the best ofmy knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signahue) - - -Date -
. ; . NOTES:
1. An Owner who obtains abuildingpermit to do his/ber own work,or an ownerwho bites an umti=gstered contractor
(not registered in the Home Improvement Contractor(FIIC)Program),will not have access to the arbitration
program or guaranty fund underb&G.L.a 142A.Other important information on the HIC Program can be found at
wwwmass.eov/oca information on the Construction Supervisor License can befound atwww.mass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.fl.) (including garage,finished basementlattics,decks or porch)
Gross living area(sq.R) Habitable room count
Number of fireplaces Number ofbedroonts
-Number-of-bathroros Number-ofhaWbaths -
Type ofheating system Number of decks/porches
Type of cooling system LI Enclosed Open
3. "Total Project Square Footage'.'maybe substituted for"Total Project Cosr,