334 JEFFERSON AVE - BPA B-14-1117, 7 REPLACE. WINDOWS 1 the Commonwealth of Massachusetts IVE
's Board of Building Regulations and Standards IN$ INC)
L S RVICE'N
Massachusetts State Building Code, 780 CMR SALENI
ed Mar� �6AJUN 2bll 024
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-l-antily Dwelling
This Section For Official U e Only
Building Permit Number: Date A lied: y
Building OtImal(Print Name) Signature ' p,�e / `
SECTION I:SITE INFORMATION
1.1 Property, dy s: ',/G,rv� 1.2 Assessors Map& Parcel Numhers
L I a Is this an accepted treef?ye - Map Number Parcel Number
1.3 'Lmtimg Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq fl) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
1Zeyuired Provided Require) Provided Required Provided
1.6 Water Supply:(i�LG.1.,c.'10,§54) 1.7 Flood "lone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Lone?
Check ifyes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owned o1 Rec t
► L --Name(Prit ��^ '— City.Sint
E
No. and Slrcet '1'elcphone Ismail AdJress
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check a hat apply)
New Construction ❑ Existing Building❑ Owner- ❑ Repairs(s) rAIterntion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number ofUnits Other ❑ Specify:
Brief Description of Proposed Work': zr {{- -\t-�-y��
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ WZZ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard CityfFown Application Fee
❑T'otal Project Cost'(Item 6)x multiplier x_
3. Plumbing $ 2. Other Fees: $ _
4. iNlechanical (IIVAC) $ List:
5. Mechanical (Fire _ ---
Su ression) $ Total All Fees: $_
Check No.__Check Amount__ Cash Amount:
(i. Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
E}3VI y5L1;)"Constru Supvisor License(CSL)
23J"�A?2 J i'AfTAi9xF{ &
�l �� License um er Ex irnt� n Date
Name or C.S,4 Holder
0
13 C A `1S M"„ F List CSI,'fype(see below)
No.and S^treet �n Type Description
Il Unrestricted(Buildings up to 35,000 cu.It.)
R Restricted I&2 Family Dwelling
Cityfrown,State,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 I Insulation
Tcle hone Email address D Demolition
5.2 Registered Home )provenent ractor(IIIC)
IIIC Regis on Nttnilmr Lr uWnD.t,
1-IIC Cron - N mne
No.and: Email address
Cit /Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be comELoted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance a building permit.
Signed Affidavit Attached? Yes ....... 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 . �4 I
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contamec ' ris ap ucati6nistrueandac un et heb stof y knowledge and understanding.
PrintOwner:orAut iorindnt s Namc( Ic-tronic Signature) D. -
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(IIIC) 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.niass.eov/oca Information on the Construction Supervisor License can be found at www.ntass.eov;ilns
2. When substantial work is planned, provide the information below:
Total Boor area(sq. fl.) (including garage, finished basement/attics, decks or porch)
Gross living area(sq. It.) 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 ofcooling system Enclosed Open --
3. "Total Project Square Footage'may be substituted for"'total Project Cost"