20 HANCOCK ST - BPA The Commonwealth of Massachusetts
F__
Board of.Building Regulations and Standards CITY OF
Nlassachusetts State Building Cade, 780 CNIR SALENI
Revisediltar 2011
ilding Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
1 This Section For Official Use Only
Building Permit Number: Date A lied:
�(� Building Official(Print Name) Signature pate
Il 1 SECTION 1:SITE INFORMATION
1 1 L Prop rty Address: r ! .2 Assessors Map& Parcel Numbers
L la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq to Fronta_ee(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 0 Private Cl Zone: _ Outside Flood Zone?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
v—s+? I4✓ icybaIC SaleM (g1+01`(?b
Name(Print) City,State,ZIP
o (aim 90�1
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed work':
vtid�• sfz t rc n;G
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
I. Building $ 117I. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3. Plumbing $ 2. -Other Fees: $
4. Mechanical (HVAC) S List: -
5. Mechanical (Fire $Suppression) Total All Fees: $
Check No._Check Amount: Cash Amount:
6. Total Project Cost: $ 619 S� ❑ paid in Full ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
�.�a✓r S ( p * License Number Expiration Date
Name of CSL Holder '
/l S No/th
List CSL Type(see below) U
51
No. and Street Type Description
�cn O ct-76 U Unrestricted(Buildines a to 35,000 cu. f[.)
C ry/Town, State,ZIP R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Sidine
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
1AC - Lot (o09 /0 3{ 3
HIC Registration Number Expiration Data
HIC Compan��Name or HIC `R—egistrant Name
��/O ftl2 Jt
No. nd Street Email address
0.L�v1n M�l- o Igrl o
City/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 .......... 19/' No........... Cl
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize C 11 y i S -Z ✓2
to act
on my behalf, in
all matters relative to work authorized by this building pe it application. 7
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNERS OR AUTHORIZED AGENT DECLARATION
By e ring my name below, I hereby attest under the pains and penalties of perjury that all of the information
con[ ' d this ar�v\
cation is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized gent's Name(Electronic Signature) Date
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 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
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dns
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. 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"may be substituted for"Total Project Cost"