2 MALONE DR - BPA I _
f � I'he C'untntunwe:thh of Massachusetts
Jh i i� Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CNIR SALE\f
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or 71au-Furei1v Uu eltol t;
This Section For Official Use Onl
Building Permit Number: Date Appli-d:
'
iu.ti-n��G�t 2 �-
Building 011icial IPrinl N;une) Signatur Date
SECTION I:SITE INF MATION
I.i Property Address: 1.2 Assessors Map& Parcel Numbers
2 Vl I AL-01,l L D2
I.Ia Is this an accepted street?yes X no Map Number Parcel Nunttxr
I.J Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq II) Frontage(Il)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c,40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check ifosO Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
�11-I.0 Ltk 5 u /X . SFI'LC At, l 11 70
Na tie(Print) City.State,ZIP
Z M (,o JC ()9—
Nu.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) & Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ I Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work-: .r;YFI VE 2 E-rr3(RlL{ `Sls(6- DE e-
7
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and .\laterials) Omcial Use Only
I. Building S SIfOD . 6U I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical g ❑Standard CirytTown Application Fee
i. Plumbing ❑Total Project Cost'(Item 6)x multiplier .x
S , ---- -------
_. Ocher Fees: S
4. Mechanical (11\':1C1 S List:-
-
. .\Itchanical ll'irr
Su t tresiion) S Tond .\ll Fees: S_. --__ -- --------_ .
o. Total Project Cost: 5 / C'hak No. __—Check Amount: _ ---_Cash \mount: _
�5�00 • �U ❑Paid in Full ❑Outstanding Balance Due:
r
SECTION 5: CONSTRIICFION SERVICES
5.1 Construction Supervisor License(C'SL) 1 1 301
Lioensc Nunther Pvp� anon I ale
N:une of l'SI. I Folder
„I ' U �o�'- List(.'SLl)pe(see helotcl
I'N PC Description
No. and Street
�/h t U b 4vesuiaed I Ihiildin�s ii m 35,000 cu. 111
`& 3���� V'l GI��� R RvAricted 1&2Famil Dllcllin
Cilyr filet n,Slule.LlP __---.... - Al Masonry
RC Rlwlin,Covering
R'S R'indow and Siding
G SF .Solid Fuel Burning Appliances
U U 3 (Q /9 SG 1 Insulation
'felt hone F.muil address D Denwlition
5.2 R`eyzistered Home Improvement Contractor(HIC) 1 y �-7/6 i f/ -
Vl
k,- G(' �C�Fe-e �'� IIIC' Registrnion Number 7 icpir:uiun Date
I IIC C'wnpan�y.un,yy )r I IIC' Ihgis rant Name
l `� U LIOII K
No. aJ Street q-�� �3(, f S Email address
Ci /Town, State,ZIP Telc hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 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 Issuan f-6c—building permit.
Signed Affidavit Attached? Yes ..........e No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as ov�M of the subject property, hereby authorizec y be to a If,in all matters re live to work authorized by this building permit application.
Print Owner's Nwne(Flc nic Signature) Date
ION 7b: OWNEW 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 2s true and accurate to the best of my knowledge and understanding.
�5 Vk ck . w\ l�A�
Print ONtner's or Authorircd,\gent's Name(Electronic Siunmure) 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 Hume Improvement Contractor(HIC) Program),will rro have access to the arbitration
program or guaranty fund under I.G.L.c. 1 a_'A.Other important information on the HIC Program can be found at
,,\% n�.n. iN �v,t Information on the Construction Supervisor License can be found at 1�0N Ip,
2. When substantial work is planned,provide the information below:
Total floor area Is+ fl.I _ —____)including garage. finished basement allies,decks or porch)
Gross living area lsq. 11.) ---_ _-_-- -- Habitable room count --- ----- _ - - -- - .
\umber of fireplaces._-- _ - _ Number of bedroom _
Nunther of bathrooms Number ot'half hallo
1'\pcof heating systen .. ... . _. Number of decks, porches _
! 1')pe afcoolhlg i)dent _ _ I'.ncloxd _ ,_ - ..Open . .
1, "Goad Project Square Footage-m:ty he substituted for''folal Project Cost"