21 HANCOCK ST - BPA viz ao-7'g
I'he C omillomi.cald: of blassaehuse[Is
i Board of Building Regulations and Standards Cffl• OF
I) \lossachusells Slate Building Cude,'790 CMR -S,\Lli\I
I G u•y)l/Building Permit Application '1'u Cbnslruel, Repair, Renovate Or Demolish a Re rie eJ
One- or Tuv:•Finr:rh Di ellifig
This Section For Olrcij t ve Onl
Building Permit Number: Ual , pplicd:
IluJdmg ORic:al(Print Nmnr) Signature
Ome
SECTION I:SITE INFORAIITION
I,I Property ST Address: 't n P dt` A 1•2 Aisessu Ala Parcel Numbers
n�l I� L,000 k �(.11L►Wy�
I.la Is this an acre Ied street? 'a no �lup Nun1h¢r I'urcul Numher
L I Zoning Informations 11.4 Property Dimensions:
Coning District I'nipused ll.va Lul Ana(x It)4 1.1 BuIldingSefbacks(R) Fn nfug a(A)
Fran:Yard Side Yards
Roar Yard
RequiredI'rvviJed Reyuirtd ProvidedNeyuirtd I'ruvideJ
1.6 Willer supply:IM.G.1.c. yd, §Sy) 1.7 Flood Zone Informations/ Zone: _ Outside Flood Zone? LII Sewage plsposd System:
Public® Privuta O
Check If cs❑ Municipd On site disposal s)stem ❑
2.1 Owner:of Records SECTION I;: PROPERTYOWNERSHIP,
m r r n r rzr,:�>?S (11', y�11�i 6�iA y1 !S
rzZa K� 97f it zy967 _ �rian�,�c�IesP�V11g1�• o
Nu.and Street relrphone
hmasl Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
Ncw Construction❑ Existing Building❑ Owner•Occupied ❑ Repatn(s)-(V Alferatlon(s) (3 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units
Brief Description ofProposed W � Z
ork': Other Cl .Specify;
r r,r 7 K1fici.Nn< '; �hS - eJew turn„ o �eSUL -
SECTION 4: ESTIAI.%TED CONSTRUCTION COSTS
hens Estinmted Casts:
I..:hor and.\I;neriais) OMCIAI Use Only
I. Building S I i0 I. Building Permit Fee: f h:dicate how fee is detrnnineJ:
'. lileclrical S Lo ❑Standard CilyrTussn Application Fee
I I'luwhil:g S Zo ❑ Total Project Cosll I Item 6)x multiplier _ --A -
'. Other Fres: S
J. \lech,mical III\ \('I S List:
q \fech.wical IFlre
i 'uw -re,sionl
n I'utul Project Cast S 'SrJ Q(7 Check \'o. ( leek .InluunC
❑P.lid In Full 0(hrtstauding 11A.mce Due:
/fib Y/
_i
tit:("1'ION 5: ( ONSI'RII(" ION SERV'l( E," lS�b t
l.Il) Iol�3�►�
SJn('onstructimt Su nse penisor Lice IC'SI.1 _ .. ., .
I iceu,a Nunlhar I
0,119
\.un¢vl'l'SI Ilnldet � y�1 .. .. .. . Ilsll'�LI)pal•cehalu+tl.__._— _ .— —
1CI)PC Mscripliun
-
�„-.ntJ 11fe' n^ n _ — - . --- tl I InreslricleJ I IhulJin 5li la
-t 15,11110 cn. Il.)
(v/'lVI_`/•V"'` �l,/' R Re�IricleJ LC? f.lulil DlscOin
SI Slltson
Cigifae n,Slala.Ll ' RC Harlin O'Nertn
µS µ'ill&%v.end Sidw
•— Sp Solid Fuel Burning \ppI1aI1Ce1
Insulation
UII `6 (• fib/ fmail:IJdr<,+ � Demoliliun
fi/�T_ef
l hw jc�60q.5
teredllume ImprovementCunlrnetor(IIIC) uln) N mMo
e 1 Illl RaplstrantName �pC)Gr9`CAeet —.Stal ZIP
SECTION 61 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,C. 132.1 25C(
Workers Compensation Insurance affidavit must be completed end submitted
permit-
No ed with this application. Failure to provide
this affidavit will result in the denial of the issuance of the building
Signed Affidavit Attached? Yes .......... O
...........G
SECTION 7s- OWNER AUTHORIZATION TO BE C0111PLETED 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
�U �b )�
e�i, n ooc p Dula
Print Owner's NWlte(hlactnuoc Slynulure)
SECTION 7b1 OWNER' OR AUTIIORIZED 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.6 Z
i'riw Un ner's or:\ulhoriraJ,\years Noma it Slynaovel
. rest
tin0ot%ilistereslinbhelHulneImprovementerinit tContrctor(HIC) Program).o do his her u%vn %tork. nollne' shavehaccesstotthearbitrati arugisicred rbitration
pmgnm or guar '1)I oil mot un an the Cuostructitin Sopery stir License l can be found at
lion on the C Program c,nsbet+lhund at
ubstamial Iwrk is planncJ, proviJe the iniurntatiun below:
\\'hens IincluJing yatage, finished basementlattics,Jerks or porch)
final Ilaur area try. I1.l . ---- - habitable room aolott _ ..
Grosi lit ing .lrca l sq. Il.t _ _ \omhet of hct1rooll"
\III,lberoflircPiacai ., ... _ - --- \omhcrof hat f hat hs
\unlhan,lhathnwn+s . . - \unlher,+Idackip„rches
I\Pu of 1w.16114 i)'1011 I'n.hLaJ ,01wil
I' Pc oI'a'olwg gaam ,
t "I,Nlal i'miacl $,lllllre I'Oi q.14e" IILIy t+e Hlhdlhllad f1V' f,ll Jl i'rUlaet Colt"