009A FILLMORE ROAD - BPA-07-284 The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
�u� Massachusetts State Building Code,780 CMR SALENI
Revised Mar 2011
Building Permit Application To Construct, Repair,Renovate Or Demolish a
_ One-or Two-Family Dwelling
J This Section For Official Use Only
Building Permit Number: Date Appli :
Building Official(Print Name) Signature Date
.9 SECTION 1:SITE INFORMATION
1.1 Pro erty Address: 1.2 Assessors Map&Parcel Numbers
( ILL-MO cE �0
((� 1.la Is this an accepted street?yes no_ Map Number Parcel Number
I— 1.3 Zoning Information: 1.4 Property Dimensions:
II 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?
Check if yesO Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 O r wne of Record:
1
Name(Print) /� ^7 City,State,ZIP
6 I�t..ly1'A*u�-+ RID 7v-- ��/� Y'/-`O PS'f5 /✓er-.Ivo f T,
No.and Street 4 S(•� aa+t� �v��
Telephone Emair Address
SECTION 3: DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addit on ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units I Other a Specify:
Brief Description of Proposed Work:
rf
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
l.Building S Gt 1. Building Perm t Fee:S Indicate how fee is determined:
2.Electrical S ❑Standard City/Town Application Fee
El Total Project Costa(Item 6)x multiplier x
3.Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5.Mechanical (Fire
Stippression) S Total All Fees:S
6.Total Project Cost: $ 32� Check No. Check Amount: Cash Amounr.
❑Paid in Full ❑ Outstanding Balance Due:
M LA I 1
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) _ Z y
5 2�, —5 • 'e j" i License Number Expiration Date
Name of CSL Holder
J/ram. Rb List CSL Type(see below) t.(
No.and Street ^ y� / Type Description
/C'O'--? 'Jry �%6 !7� U Unrestricted(Buildings up to 35,000 cu.ft.)
CffylTown,State,ZIP f Restricted 1&2 Family Dwelling
M viasonry
RC Roofing Covering
WS Window and Siding
Tr ty� / !� SF Solid Fuel Burning Appliances
6C `r (J,�6 I&~,! &;?c i-ie!7, e,v�� ��.G�'G` 1 [nsulauon
Tele hone Email address D Demolition
5.2 Regi-stYer�ed Home Improvement Contractor(HIC)
Pee, �' HIC Registration Number Expiration Date
HIC Company Name or HIC,*R�eg�smo t Name
Y /C�I eC
A-1 ei OC-11C <�/�_ � �� - Email address
Ci /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
��
1.as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit app cation.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER[ OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of die information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home 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
e _Information on the Construction Supervisor License can be found at,___=__._,_;: ___
2. When substantial work is plaunedy provide the information below:
Total floor area(sq,ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"