0007 COLUMBUS SQUARE - BPA 10-268 ROOF The Commonwealth of Massachusetts •r0"'w City o —<;4k
State Board of Building F' Office of the Inspector of Buildings
�V Regulations and Standards E` -
Massachusetts State Building c
Code �vpc
780 CMR
APPLICATION TO CONSTRUCT,RYPAIR,RENOVATlE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
` This Section Fo4 Official Use Only _-
'.Building Perm
i IN Vlrer. Date Issued: -
Signature: .:,
:Building Commissioner In pect r f Buildings - ; . , Date
SECTION 1—SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Number
r
• r4'1 414SMap Number 'Par( Number
1.3 Zoning Information: 1.4 Property Dimensions:
ri
Zoning District Propeny Use Lot Are miti e-(R) I (
Buildin•Setbacks rt ( 1 i 17
Front Yard Side Yards P.C.r Yard I
Required Provided Required Provided R uired I divided
/ / % �I( , � I I
1.6 Water Supply(M.G.L.c40.§54) 1.7 Flood Zone EIEo[otion: �,9,,S�e fig ,Dlispo�sa8 stkrb: ;
Public ❑ Private❑ Zone; E utside FlooP' MumCipal pn srte des cal system ❑
'SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT ! 'I
2.1 Owner of Record: �� � � � (✓� � � � i '�
Name(print) ,li •' j Addrs
Si nature / ) } 1 t ( { i Tele I ne
I
2.2 Authorized Agedt t/ \/
�
Name(piini4 I I , � Address
Si nature 7f PI-1 Telephone
"•_ SECTION 3—CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF , *:
: .ENCLOSED SPACE "
Licensed Coostructiou Supery or Not Applicable o
Name(print) License Nu ]ber �
e Y e0 At lar /4VG .�Cr �z
Address
4�� Expiration D to
signature
Registered Home Imp vemer Contracto _ Not Applicable❑
v , 't fD��s
Company Name
y�� �K ��/� �v� License Number
Address�� t� � -6
Expir t on Dat
Signature Telephone
w-r
SECTION 4—WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a 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...I No......I
SECTION 6—DESCRIPTION OF PROPOSED WORK(check all applicable) r
New Construction 77 ❑ stin Buildin Exi 0 Repair(s) ❑ Alteration ❑ FAdditom ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify:
Proposed Use: Single Family Dwelling C Two-Family Dwelling ❑
Brief Description of Proposed Work: �1
SECTION 6-ESTIMATED CONSTRUCTION COSTS > All Building,Wiring,Plumbing,Gas,Fire Suppression and Alarm Fees
Item Estimated Cost(Dollars)to be will be paid by the general contractor or owner at time of issuance.
completed by permit applicant :Official Use Only
1.Building (a)Building Permit Fee Multiplier'
2.Electrical (b)Estimated Total Cost of
Construction from
3. Plumbing Building Permit Fee
4.Fire Protection (a)x(b) -
5.Mechanical Check Number,
6.Total= 1+2+3+4+5 --
SECTION 10a-OWNER AUTHORIZATION—TO BE COMPLETED WHEN -
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT i
4 y,
/�< L as Owner of the subject property hereby
Authorize v to act on my behalf,man or the relative to
work aut ized by this building pe '[application. /
Sig,;atemof Ow.d7 Date
SECTION IOb—OWNEWAUTHORIZED DECLA ION
L r - a f e"—as Owner/Authorized Agent hereby declare that the statements and
information on the oregoing application true and accurate,to the best of my knowledge and belief
Signed unde the pains an enalties o perjury.
C �e b° 3 L�
Print Na
—Signature of Owner/A ent Date
FEE BREAKDOWN OFFICIAL USE ONLY Notes:
Estimated Cost
ITEM MULTIPLIER FEE
Building
Electrical
Plumbing - -
Gas
Total Permit Fee