24 LAFAYETTE PL - BPA ol �oa�
�J fhe Commonwealth of Massachusetts CITY OF
B
oard of Building Regulations and Standards S\LE-M
Massachusetts State Building Code, 780 CMR Revi.sed.tlur 2011
Building Permit Application To Construct, Repair. Renovate Or Demolish a
One-or Ttvu-Funtily Deelling
This Section For Official Use On
Building Permit Number: Date Ap li
7
Building Ot7icidl(Print Narne) S it ture Date
SECTION I:SITE INF MAT
I Pro eyt A dress:�e1 1.2 Assessors N ap& Parcel Numbers
�if 2g n ye, &ce
1.1 a Is this an ace pted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required PruviJeJ
1.6 Water Supply:(M.G.L c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposals)stem ❑
Public❑ Private❑ al Check ifyes❑ P
SECTION2: PROPERTY OWNERSHIP'
wngriofRgc/rld/e� rer� J ai97d
LL !!77 M1
N ume(Pan ) Cit State,ZIP
2 �Z�,c e ? Ur�fl11L
No. and Street _T Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other kSpeci(v:
Brief Description of Proposed Work':
w-, tux 6ZT - �
J
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building S 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 7. Other Fees: $
a. Mechanical LI-IVAC) S List:
5. .Mechanical (Fire S --
Suppression)
'Total All Fees: S
�1 Check No. _Check Amount: _Cash Amount____
6. Total Project Cost: S �Of/ ❑ Paid in Full �pq ❑Outstanding BalanceDue:
/h((
/ , 0 4n P t l cva e-Q�,
SECTION 5: CONSTRUCTION SERVICES
5.1(C'onstruuctiun Supervisor License(CSL) CS 36 8a YI21/20/2
_v r'/ ?11 Al 61 ZZ fdlh Licctuc Nmnhcr lispiralinn Unto
N;une ul' 'Sl. I Inlder
/Lrn QLs /� List CSL Type Isce belotvl_- ___
No. and Street Type Description
Q� r//J7 O Zr ` / U Unrestricted(I3uilJin Ts u to 35,000 cu. 11.)
1 R Restricted I&I Fanil Dtrellin
Citylrown.State. .II' M Masan
CS 3 I ItC Roulin Coverin
WS Window and Sidin •
1
/2 7� 7 D SF Solid Ivel I3uming Appliances
CO / 1 7 _ I Insulminn
"I"CIC hone Itmail address U Demolition
5 Registered Home Improvement Contra for(/7F�1C) ��/ l 1 9 7 /L �`24 f 2� 3
GCompa Lf7/'h i� f AJ1; l yy� (sJtf blfs �(�t�tl r( IIIC Registration I:apiruion Date IIIC C ompa and• r I l (ReglStrallt amcrj / a
��G K(/L
No.;u1J Street /' I r{ 402021
^02( M JOZI � B Email address
5 ' DC� /1 C
Ci /Town, State,ZIP fele hone
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 .......... ❑ No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FO BUILDING PERMIT
1, as Owner of the subject property, hereby authorize
to act on my behalf,in all platters relative to work authorized by this building permit app tcation.
7'ut4L L f/ A reties 411-12/ z; l
Print Owner s Nunle(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 curat to the est of my knowledge and understanding.
/`�� Ke- �r��, /� ��� 9/21/2o i1
Print Owncr s or Authorized Agents Name(I.lectronic Signature) Dale
NOTES:
I. 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
y uy.mq....g,p__rcq Information on the Construction Supervisor License can be found at tt k n a_s.g 1� dos
_' When substantial work is planned, provide the information below:
Total floor area(sq. R.) _(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 --__
1, pe of heating system --------_----- Number of decks, porches
Typc ofcooling system
------- ------
3. "Tonal Project Square Footage-may be substituted thr roml project Cost-