1 KERNWOOD ST - BPA B-2010-802 The ('unununoralth of ;%IasstichuSCttS Rik
Board of 131.111ding RC11u1ati0ns and St ind:u'ds
Massurhuse is Stutz Building Gude. 7111 ('NtR• 7 Cditiun I tilt
^, Building Permit Application To C�nnsu'tuL Repair. Renovate Or I)Cnxilish a
` l One- orTiro-FamilyDuellitt,G
This Section For Official Use Only -- --
Building Permit Number: Datz Applied:
! 2 � S Ja/1 d - - — --
s il,nat nre:
Building Cummi,sioncr/ Inspenor t Buildin1Vs Date.
SECTION 1: SITE INFORMATION
Ll P/roperty :Yddress: 1.2 assessors map & Parcel Numbers
11 'Lf(YW 00� S"f. J(.t��Xp - - -----
Pao:el Nwnber
I.Ia Is [his:In arcepli'd soeet? yes no !vla
_ P Number ..
1:3 Zoning Information: ° 1.4Property Dimensions:
Zoning District Proposed Use Lot Arca(sq I.0 Froniagc alit
1.5 Building Setbacks(ft)
Front Yard - Side Yards - Rear Yard
! Required Provided Required Provided Required Pro,ided
1.6 Water Supply: (M.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? ,'otunicipal ❑ On site disposal system ❑
Public ❑ Private❑ Check ifyes❑
SECTION 2: PROPERTY OWNERSHIP'
21 Owner'of Record: ✓t?rrlwooCj }Address for Service:
- - Ke nt a Qx\ C rti )[ks1 CA6'Q 1t��
v
Cam IPrinl) // C1q _
Si_enaturc Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction ❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ :\dJilinn Cl
Demolition ❑ Accessory Bldg. ❑ Number of Units_- Other ❑ Speedy:
Brief Description of Proposed Work-: " V� c �'
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials)
IWdi
I $ �5�� (�(p L Building Permit Fee: $ Indicate how fee is deietill ej-
❑ Standard City/Town :kpplication Fee
2. l S ❑Total Project Costs (Item 6) x multiplier x
3. S 2. Other Fees:�. ral HVAC) S List:Sal (Fire y Total .411 Fees:Su ) -
(_ Check No. Check Amount: C:Ish Ani:wni:___.jb. oject Cost: S /SROco 0 Paid in Full ❑ Outstanding Bidance Due:___..__
r
SECTION 5: CONSTRUCTION SERVICES
(5.1 License11d Con\s_tructioti Supervisor (CSI_) M S-7:712,
Chri STo Cwt 1e C' Lin•nse Nmnhet Fspinal"11 Date
Nance of„�I_- I to der
II� Iv�� etn Luc CSL'I'cpc(srr hcluw)
7\ c - Descu num
1 L' L'nresuacied nt i m:i.000.Cu. Ft.
. R Restricted MC'_ Funds D"elline
Sicnat�uyra r� - \7 \tasonn Only
RC Residential Ituuline Co�enn„
Telephone \\'S Resldennal \\'IndU\\ .Md SiJuc
SP Residential Solid Fuel Iiurmne \ i�baucr,lu,t.tlLwui�
'- D Rcsidenual Demulmun
5.2 Retzistered dome Improvement Contractor(HIC)
(`hrts C�h er 7-0C-z-1A —
IiIC Company . at e or MC Registr ' arae Regutrauun Number
(0Ia(OIID
AJ
Expiration" Date
47&-'7�I,i
Signature Telephone _ -`--
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. 9 2506))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure at pruaide
this affidavit will result in the denial of the Issuance of the 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 l NL GK.tc_ /t Gt u1SU h as Owner of the subject property hereby
authorize � � �'C'r'i Ct C iT ClC to act on my behalf. in all mzttet:s
relative to work aauthorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I. �I h i d P. r 2dl ���' as Owner or Authorized Agent hereby declare
that the statements anc intbrmation on the foregoing a lieation are true and accurate. to the best of my knowledge and
behalf. �{� rC I J7 6r Z(
Print Nat 'i`,7(—J the
ignature of Owner or A torized .Agent Date
ISie led under the sinsjffnd penalties of perjury)
NOTES:
I. `1n Owner who obtains a building permit to do his/her own \vurk, or an owner who hires an unie:_istered contractor
(nut registered in the Home Improvement Contractor(HILI Program), will not have access to the arbitration
program or_ituaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 1 I O.R6 and I IO.R5. respectively..
?. When substantial work is planned. provide the information below:
Total flours area tSq. Ft.) )including garage, finished hasement/anics. decks or porch)
1 Gross livine area (Sq. Ft.)' Habitable room count _
Number of fireplaces Number of hedroom.,
Number ut ha[hntoms - Number of halt/hath,
rvpe of heating system Nwnber of decks/porches -----__._---
Type of cooling system Encluaed 0pcn
3. "Total Project Square Fonrtge" may be substituted for "Total Project Cost"
J