0005 COLUMBUS SQUARE - BPA-12-1054 DECK \
he C'o III III on%%eaIIII of NlassacIIuscIts
Board of Building Regulations and Standards CITY OF
(I t Ntassuchusetts Statc Building� Code. 730 C'RIR He l'i.M,/ 1IJ/'_'ll//
O L,
Building Permit I\pplicatiun 'fo Construct. Repair. Kcnovatc Or Demolish a
Urn'•or rive)-PlimilY Divellhi.q
This Section For 011ficiul Use Only
Building Permit Number: Date:\ lied:
�\ _�Z.z�fCvc.a
IJuilJing 011idal(Print N;une) Sign a Date
SECTION I: SITE INFO NIATION
.1 Property Addres A 1.3 Asijessors Hap h Parcel Numbers
om r5 V _
I.In Is this an accepted street? 'es no Slap Numhur Parcvl Nun,l+cr
1.3 Zoning Informution: 1.4 Property Dlmenslons:
Zoning District 11n,poseJ Use Lilt Area(sy II) Frontage(II)
1.5 Building Setbacks(R)
Fruni Yard Side Yards Rear Yard
Required Ihuvidvd Required Provided Required Provided
1.6 Water Supply:IM.G.t.c. )U.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Ihlblic❑ Private❑ — Municipal❑ On site disposals)stem 0
Chock il' �cs❑
SECTION2: PROPERTY OWNERSHIP'
2 �Ownert f Record: / J �
0 ,r(�a.n Sa 'POYI. M
N.un• Irrint) City.State,ZIP
Co(u b05
No.and Street relephune Finail Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ E.xisting Building❑ Owner•Oceupied ❑ Repairs(s) 1/ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specily:
Brief Description of Proposed Work :
SECTION 4: ESTI,NIATED CONSTRUCTION COSTS
Itvllt Estimated Costs: . Official Use Only
ILahur and..\laterialsl
1. Building S I. Building Permit Fee: S Indicate how tee is determintd:
❑Standard Ciry)Tussn Application Fee
2. Llvorical S ,
❑Total Project Cost (Item 6)x multiplier _ ,—_ .r
I. Plunihuig S ) q00 2. Other Fees: S.
J. \Iveh.Ini:al III\ WI ) List:
5 Vvchanic,ll IFnv S ---- --- -- --- -- ..- . ... ._
1u 'rcisuml rota \II Fees: S
/ ('IIQ A No. ( Iud, Annnun: ('.I�h \jtwon :
F I. fugal Project Ciol 1 `q 0 P.Iid in Full ❑Outstanding Ilal.uyce Ouc:
SE('I'ION 5: CONS'I'RI1CI`ION .NERVIl'ES r
5,1 ('mtstruction Supenisur License(('SI.) b b 2DI
n' 59 �_.
-__10 _ .. .
ICC11w Nmnher f\liratl nI Data
.R.uneul'l'SL IldJcr
I ul l'SI. I'%Ix I see helots 1
PC
No' Ucx'riplian
No. and Slrcet
+' ---.. . .-- t Inrcxlr'.J 1lluddin`s li l0 1t,11110 al. It.)
�Ofh (�1l �.. ,a _ I(nlrietcJ LC? Panld Ihscllin
Cityi
li(' Rulttin Co�erin
SF Solid Fucl(turning Appliances
Gl�z �0 D} OQ?� n2Pz I tt� 17MAif CcNY) I I Insulation
I'cic hums -r— Email a nss !) Danlulitiun
5.2 Registered Ilume Improvement Contractor(FIIC)
IIIC' Itell6taniun Number F%piruliun Date
I IIC C'ampan) Name or I IIC I(agistrunt Noma
No. and Shoat Email uddress
City/Town. State ZIP relc hone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 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 .......... Cl No........... O
SECTION 7s: 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 U%Ntler's Name(Electronic Signature) Dote
SECTION 7b:OWNER( OR AUTHORIZED AGENT DECLARATION
9 ntering my If ne to , I hereby attest under the pains and penalties of perjury that all of the informatiun
lc nr din h ti n is true and accurate to the best of my knowledge and understanding.
I'ri a Ua cr's ur \mhurireJ,\grnt's Nnme I lilccuunic Signaulral Duty
No'rEst
1. .\n Owner who ubiains a building permit to do his.her awn work,or an owner who hires an unregistered cuntractur
I nut registered in the Hume hnprovanient Cuntractor(HICI Program), will nu have access to the arbitration
program or guaranty IunJ under\LG.L. a. 11?A. Othcr impunant information on the HIC Program can be found at
Isls,s 11,.n. .., % .-..1 Information on the Cunstruction Supervisor License can be found at tit 1,; % -Ip,
2. \%hen substantial ssurk is planned,pruvide the hilbrumtion below:
rotal Iloor area 114. Ii.) _ 1 including garage, finished basement attics.Jocks or purch t
Gross 11%ing ,ueaIiq. it,I flabilubleruum "um .
1 \umber ol'Iircplaccs Number of hcdruulus
\umherofhadirroms . . . . . \lunberol'hnllbuths
I\pcot'hcatingsyrlenl _ \lmlberol'Jecksporchcs
111`c PI iPUlnlg i\Q81❑ l'I1C 1UidJ (ll.e ll
t
� "I,ILII P/,Ijhl ti1111a fa I'Ji`IJ 4e"111;1\ he NIthIlltlil'd luf"fU1.11 PrujeCl (Ill' •
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