3 INTERVALE RD - BPA-14-167 q The Commonwealth of Massachusetts C('CY OF
Buard of Building Regulations and Standards
I Massachusetts State Building Code, 730 QvIR SALE&I
Building Permit Application To Construct, Repair, Renovate Or Demolish a Ravised blew 1011
One-or five-Family D:velling
'rhi3St!ctioAF6rOfficiaiUsi0fily.
Building Permit Number:. Daf` , ppliedr
Building Offici (Print Name) Tigna Date
SECTION 1:SITE7NFORINEATION
1.1 Pro ertyAddrela: �\� ` 1.2 Assessors Map&Parcel Numbers
L I a Is this an accepted�street?yes tnoo Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage(it)
1.5 Building Setbaclts(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided '
1.6 Water Supply:(M.0.L c.40,§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Public❑ Private Q Zone: _ Outside Flood Zone? Municipal Q On site disposal s stem Q
Check if esQ P P Y
SECTION2, PROPERTi!'OW(VERStiD?!
xz-
2� Qwnert of Rec`or�d \ —^���
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF.PROPOSED WORW'(cheek all that apply)
New Construction C1 Existing Building❑ Owner-Occupied Q I Repairs(s) ❑ Alteration(s) Q Addition 0
04molition Q Accessory Bldg. ❑ Number of Units_ Other 0 Specify:
Brief Description of Proposed %Vork : e
SECTION 4: ESTIYLAIED CONSTRUCTION COSTS
item Estimated Costs: Official Use Only.,
Lahor and�latecials ..
I. Building S I. Building Permit Fee:3 rndicate haw fee is determined:
?. Glcctrical y QStandatd.City/fowrFAppiication Fes
❑'CotalProjectCost'(item6).vmultiplier x
1. Plumbing i ;. Other Fits:'.S
I ,\faehanic.tl (IIVAC) > List:_
i. \lech.mir.il (Piro
cs;iun) S Total All Pecs: S
ClierlNo. Chcc!e,luwuut: _l'.sh :\nunint:
� , fnlall'rnleet ( ' ,�t S Za00r � (] Itii,linlnll Ol)ut;tawliuglL,I:uieol),w: - --
,
SEC'l'ION 5: cwis•rRUCHON SEitVICES
5.1 Cunslructiott Supervisor License(CSI,) —
License Number Gspiratiuu Uato
Name of CSL I lolder List CSL type(see below)
Type Description
No. and Street U Unrestricted Duildin s up to 35,000 cu. tt.
It Restricted 1&2 IrMully UNYU11111it
City/rown,Stute,ZIP I Roor nr
RC Ruutin Cuverin
WS window Imd Sidu
SF Solid Fuel Burning Appliancm
( Insulation
1'ele hona
Email address U Demolition
5.2 Registered Home Improvement Contractor(H(C)
IIIC Registration Number Expiration Date
I I IC Company Nnma ur I IIC Registrnnt Nama
Email address
No.and Street
Ci /Town State 'LIP Tale hona
SECTION 6: WORKERS'COMPENSA'T[ON INSURANCE AFFIDAVIT(M.G.L.c. 152. g 25C(6))
Workers Compensation Insurance affidavit must be complated 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..........❑ No...........0
SECTION Tat OWNER AUTHORIZAT[ONTO DE COd[PLETED WHEN
OWNER'S AGENT OR CONTRA 1:TOR APPLIES FOR BUILDING PERhHT
1, as Owner of the subject property,hereby authorize
to act on my behalf, in all matters relative to work authorized by this building pennit application.
Dnta
Print Uwner'f Noma(Eleetrmtic Signalura)
SECTION 7h: OWNER( OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
contained in this appiicadn(n.,i$s.true and occur t e t of y k awiedga and understanding.
�i `� °� D,Ite
Print cvn.a's ur Autlturieed:\gelt'a N,une(Elecuunic Signa tire)
NOTES:
Owner who obtains a building permit to do his/her own work,or on owner who hires an unregistered contractor
(nut registered in thu Mont: improvement Contractor(HIC) Program),will tar have access to the urbitratiun
progrun or guaranty tiutd under M.G.L. c. I I2A. Other important information un the HIC Program can be found at
Iv,vw art;+ �.arv%oc;t Intbnnatioa un the L'unstrttction Supervisor Liccnse can be found at Itvvxymws. -� v�,ILt
2. When substantial work is pLmnad,pruvido the information beiuvv:
Ibral hour area(;q. tt.) ___. _(including garige, tinisheJ hasemeaVattic;,decls or porch)
Itib,tablc room count _
(lros; livin';:u'ca(';Il. lt.l _-- ?lumbatofbe,lruom:t --_._--
NlnnbCroftiraplaCc; _---
------ --- Nnwhcrofh.11tb.nhs
--
�Iwnhcr elf b.lthnns au —_-- ----
-' " \J,IIIII)irUtdCc6 ' I'lll'iltCi- ------
_
le ,lf h;.uing ;y;Icnt ------
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� t .. I.rt II I'r,q:�.t �.pl Ir.t I' „'t.l :�•.ul.ry bC ;nl+.tnnl_ I I,n' I, r.11 I'nq ;�t 11r_ti'