12 HARRIS ST - BPA B-2015-89 0
The Commonwealth of Massachusetts
Board of.Building Regulations and Standards IN$PE CITY OF
a 7 Massachusetts State Building Code, 780 CNIR S/�L€tl Wo
{� �j ,a 21lis�c`.b1ar 2011
Building Permit Application To Construct, Repair, Renovate Or Dem�C�h a
One- or Two-Family Dtvel ing
This Section For Offi 'al Use Only
Building Permit Number: Da Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Pro erty Address:
f /a Pr - L2 Assessors iVlap & Parcel Numbers
\\e !t Cc t-i''r S �'�"
\� l.la Is this an accepted street?yes_ no Vlap Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
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: (�LG.L c.40,§54) 1.-Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if yes'❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
-t' a✓✓i t In a i yrLe _!-SZy,Lw.v j'I'1,1�G 19 76
Name(Print) City, State,ZIP
I.;? 97i-r-y-a 5DS-783— 9Y� ¢ cell 9�A 7�!3538
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) Q� Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': j/ -Q! A'f'. 8 ✓ i,1 Q�Q at
W�✓)dn,.tJ S
SECTION 4: ESTINIATED CONSTRUCTION COSTS
Item Estimated—Costs
(Labor and Materials) Official Use Only
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Costs(Item 6)x multiplier x
J. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) S List:
5. Nlechanical (Fire $ - —
Suppression) Total All Fees: $
6. Total Project Cost:
Check No. Check Amount: Cash Amount:
l5J / ❑ Paid in Full ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration �
Name of CSL Holder
// S N�/1-h
List CSL Type(see below)
5�
No. and Street Type Description
/et —�� U Unrestricted (Buildings a to);.Arta cu. ft.)
R Restricted I&2 Family Dwelling
City/Town, State,ZIP NI Masonry
RC Rooting Covering
WS Window and Siding
t� SF Solid Fuel Burning Appliances
�W-00 4 / I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
A4-- t( "Szv,V Inc - IDl (oo9
HIC Registration Number Expiration Date
HIC Company Name or HI1C' `R_egistrant Name
No. nd Stree�Zt.V, M let_ C) Email address
�.n Iy� L
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 .......... I9/' No ........... ❑
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 071I L r S
to act on my behalf, in all matters relative to work authorized by this building pe it application.
� (o ,jl-o, - i -aa- lS
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNERS OR AUTHORIZED AGENT DECLARATION
Bye nring my name below, I hereby attest under the pains and penalties of perjury that all of the information
con[ ' d this a lication is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized gent'a 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/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. 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"