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0072 FLINT STREET - BPA-10-252 i The Commonwealth of Massachusetts Town of Board of Building Regulations and Standards Massachusetts Slate Building Code, 780 CMR, 7'"editionja Building Dept Building Permit Application To Construct, Repair. Renovate Or Demol One. or As o-FamilY Date ing dkvma This Section For Official Use Only Building Permit umber: Date Applied: signature: C)9 D Budding Commissioner/Inspector of Buildings Date SECTION I:SITE INFORMATION 1.1 Propertyy Address: 1.2 Assessors Map& Parcel Numbers 1.la Is this an accepted street?yes no Map Number Parcel Number IJ Zoning Information: 1.4 Property Dissensions: Zoning District Proposed Use La Arca(sq R) Frontage(R) 13 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: Outside Flood Zone? Municipal O On site dis sal s stem ❑ Public O Private❑ — Cheek if esO p Po y SECTION2: PROPERTY OWNERSHIP' 2.1 Ownert of Record: ALA,V �16 5� lee4gly�b` NL�EDINf+hk M OZ`�951 Name(Print) Address for Service: 509' 7zy 2-Z97 Signature Telephone SECTION l: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction O Existing Building❑ Owner-Occupied ❑ I Repairs(s) O 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.O Number of Units_ I Other ❑ Specify: Brief Description of Proposed Work': 1 t_ 7 SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building S I. Building Permit Fee: S Indicate how fee is determined: ❑Standard Ciry/Town Application Fee 2 Electrical S O Total Project Cost'(Item 6)it multiplier x J Plumbing S 2. Other Fees: S 4. Mechanical (HVAC) S List: s Mechanical (Fire S Total All Fees: S Suppression) Check No. _Check Amount: Cash Amount._ 6 Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due: SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) (n> J 7 g(6 1111,61J.7 r' II __ld I ' � �L License Number Expiration Dale f U>Pi�n2f � f�U 4 Nyoe of CSL It Wer List CSL Type(,cc below) 31 s . 4 1Akt ct-z A, ©I S SD Address RD Description RestriUnrescted 1 u to Family D0 Cu. Ft. Restr¢Ird I&2 Fared Dwe1Ln Signature .Mason Only S'bA 72L ZZy? Residential Roofrn Covering Telephone Residential Window and Siding Residential Solid Fuel Burning Appliance Installation Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Company Name or HIC Registrant Name Registration Number Address Expiration Date Signature Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.J 2SC(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 AfTidavit Allached? Yes .......... Cl No........... O SECTION 7s: 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 application. Signature of Owner Date SECTION 7b:OWNER` OR AUTHORIZED AGENT DECLARATION 1, , as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. / - G./I U.� 9,! Prim Name 9 �tl n Signature o Owner or Aulhoriz gent Date P (ISillnedunder the pains aridstenkWees of perjury) 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 W have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS, respectively. 2. When substantial work is planned,provide the information below Total floors area(Sq. Fl.) (including garage, finished basemenUatlics,decks or porch) Gross living area(Sq. Ft.) Habitable room count ,'umber of fireplaces Number of bedrooms Number of bathrooms Number of halfbaths Type of heating system Number of decks/porches Ty pe of cooling system Enclosed Open 1 "Total Pro)ect Syume Footage"may he suhstilutcd for 'Total Pro)cci Cost"