3 INTERVALE RD - BPA-12-735 J31 . o 0
7 Ilac C'unnnumreahh of Massachusclts Board ufBuilding Regulations and Standards CI I')'OF
Massachusetts State Building Code. 780 C'NIR SALIAl
q YJ► 'L,.,. Reri.rs•J I b¢_'ll//
Building Permit Application To Construct. Repair. Renovate Or Demolish a
One-or Tlcu-f ianrilP Dwelling
This Section For.,OtIricial Use Only
'Building Permit Number: Date Applic _
e — `
lluildin8 OIlicijI(Print Mane) Signature Date
SECTION I:SITE INFORMATION
I.I Pro erty Addrea: 1.2 Assnwn blap ureel Number
1N 1�:7 t� l�
I.la Is this an accepted street? 'es no Nap Number Purcel Number
1.3 Zoning Information: 1.4 Property Dlmenslons:
Zoning District Proposed Use Lot Area(sit Iq Frontage(II)
1.5 Bullding Setbacks(fl)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.C.I.c.JU.§!J)tZune1 Flood Zone Inrormallon: 1.8 Sewage Disposal System:
Ilublic❑ Private❑ : _ Outside Flood Zone? Municipal
Check it' es❑ ❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2. Ownert of Record:
0- kmo- 8 61-A E G A-tj'T}Ft OVL
Natne(Print) City.Slate,ZIP
Nu.and Simet Telephone E&nuil Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteralion(s) ❑ Addition ❑
Dennlition Cl Accessory Bldg. ❑ Number of Units_ Other ❑ Speeil'y:
Brief Description of Proposed Work%
/,ITCI+E�1 K�IH60
SECTION J: ESTIMATED CONSTRUCTION COSTS
item Estimated Costs: Ofllclol Use Only
(Labor and..\laterials) y
I. Building S 1. Building Permit Fee: S Indicate how Ice is determined:
2. Flectrical S ❑Standard City,Tosvn Application Fee
❑Total Project Cost'1Item 6)x multiplier .x
?. Plumbing S ,. Other Fees: S - ...-- -
J. .MMI.utical ill\' W) S
5. \leclt.mical iFire -------- -.-...-_ . . .
So'I res.uml S total .\Il Fees:
('heck No, ('heck Amount: C.Ish \ninuu:
�! n Total 11roject Ci i r - — _..-._..
N�o00. 17 PAd in Full ❑Outstanding Ilal;ncc Due:
e2
r`p 4o Pm,e ot..,-e i
0-!- C�
7- h
SE("PIONS: CONSI'RUcriON SERVICES
5.1 ('onstruction Supen'isor License(('SI.)
I icense IVuother .. .. F\piration Pate '
N;onc al t'SI. IIuIJcr__ __ _
I Taal l'SI. I)Fe Uee henna 1,_
I..,PC Dcscripuon
No. and Street ----------'.._.
U I 19uddin n ti to 33,000 nt, It
K Itcetricled III I amill Dacllin
Cit\i fart n,titate.Lll' -- .\I \laiuu
RC Rrwlin Oncrin
N'S Window:md Sidin
SF Solid Fuel Iluming Appliances
I Insulation
1'cic hone Finail address D Dcmolitiun
5.2 Registered Ilume improvement Contractor(HIC)
IIIC Registration Numlwr h\pirtaion Date
IIIC C'ompinl Nance or IIIC Itcgistrunt Name
No. and Street L'mail address
CityfTown.State ZIP Tele hone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 132.1 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 .......... O No...........0
SECTION 7a: OWNER AUTHORIZATION 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 Uwner's Nmne(Electronic Signature) Date
SECTION 7b:OWNERI 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 omicr'i ar:\ulhorireJ Agent's Name(Flectruoic Signature) Data
NOTES:
I. An Owner whu obtains a building permit to do his.her own work,ur an owner who hires an unregistered cunlrnctur
t nut registered in the Hume Improvement Cuntractor(HIC) Program),will t have access to the arbitration
program or guaranty Nod wider M.G.L. C. 143A.Other important information on the HIC Program can be found at
ttar\ n ,t.. �.t .v.i Information on the Construction Supervisor License can be found at
I \\'hen substantial work is planned, provide the int'unmatiun below:
fatal flour area 1,y. R.) . I including garage. finished basement attics.decks or porch)
Gross li\iog area i sy. ll.l .._.._. Habitable room count __. .... .
\anther of lircplaces .... ._ _.-. _... ._ Number of bedrooms
Numhcr of hathrooms \umber of hall'hull's
I\pe of heating s%rlem - . . \omher ol'decks, porches
1\pe. l cOrdlllg i\itelll I,IIc IoieJ Open
1. "I'at,d llrojcct Square Footage" m;q he iuhitiuucd ILr"11na1 project ('list"