7-7 1-2 HANCOCK ST - BPA The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALENI
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Famil,v Dwelling
This Section For Official Use Only
Building Permit Number: Da[ Applied:
Building Official(Print Name) Signs✓ In Dat
SECTION 1:SITE INFORMATION
1.1 Pro city Addr 1.2 Assessors Map& Parcel Numbers
I.I a Is this an accepted street?yes_ no Mop Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning DisiriU Pro ulc AUse Lut Arc,(sq 11) Pnaasgc(tt)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rcar Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(NI.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Privale❑ Zone: _ Outside Flood Zone'?
Nl
Check it yes❑ unicip,l ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERS1111"
2.1 wner,of Reel A:
Lqh 4v _ F
Name(Print) City,State,ZIP p y
�7 1�1r'lL( � q28 �47 T —15 1/I
No.and Street Telephone Ismail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ :AIteration(s) ❑ Addition ❑
Demolition ❑ Accessory 13Idg. ❑ Number or Units I Other ❑ Specilq:_
Brief Descri tion of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
I. Building ,$ i i I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ .,
:. Other Fees: $
4. Mechanical (IIVAC) $ List:_
5. Nlechanictd (Fire -
Su i ression) $ Total All Fees: $_ _
6. "Total Project Cost: $ Check No. _Check Amount:__Cash Amount:
D S W ❑ Paid in Full ❑Outstanding Balance Due:
it r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
y lt�wt.4!, S License Number Expiration Date
N.une of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.RJ
�
7 R Restricted 1&2 Family Dwelling
Cirylfowu,State,ZIP
M Masonry
RC Roofing Covering
WS Windowand Sidin
S I Solid Fuel Burning Appliances
I I Insulation
Tele hone Email address D Demolition
5.2 Registered Flame Improvement Contractor(HIC) I-72?10
)110 t' r 4 U e-- HIC Registration Number Expiration Date
HIC omplfiry Nameor ilic Regisirm[ ame
Y<y, 3c,�-
No.and Sir, t
5C7;P `�'�� d jC� ALL 1-76zl Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'CONI PENSAT ION INSURANCE AFFIDAVIT(NI.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 .......... gi/ No........... ❑
SECTION 7a: OWNER AUTIIOR►ZATION 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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's N:unc(P.leclnmic Signature) pate
NOTES:
1. 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 Flome 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
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
2. When substantial work is planned, provide the information below:
Total Floor area(sq. ft.) (including-garage, finished basement/attics,decks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplaces Number of bedrooms _
Number of bathrooms _ Number of half/baths
"Type of heating system _ Number of decks/porches
l'ype of cooling system__ Enclosed___ Open
3. "Fotal Project Square Footage"may be substituted for"fotal Project Cost"