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5 MANNING ST - BPA (jacket info.) NThe Commonwealth of Massachusetts � Board of Building Regulations and Standards Town of kIf Massachusetts State Building Code, 780 CMR, 7ih edition Wilbraham Building Dept Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800 Otte- or Two-Family Dwelling Ext 118 This Section For Official Use Only Building Penni N mber: Date Applied: Z J Signature: Bw g Commissioner/Inspector of Buildings Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 1.Ia Is this an accepted street9 s no Map Number Parcel Number 1.3 Zuni:.g a:fo:.—.aiiou: - --- 1.4 Property Dimenslnns: i I Zoning District Proposed Use Lot Area(sq ft) Frontage(R) 1.5 Building Setbacks(it) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ _ SECTION 2: PROPERTY OWNERSHIP' _ 2.1 Owner'of Record: Name riot) Address for Service: —Sign.r — Telephone SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply) rNew Construction❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑molition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: ef Description of Proposed Work', SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Su ression Total All Fees: $ _ Check No. Check Amount: Cash Amount:__ 6. Total Project Cost: $,ODD ❑ Paid in Full ❑Outstanding Balance Due: P_�6 /0 0171�2--69171Z_- r SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) ©OS3 �e License Number Expiran�on Date Na ofCSL-Holder Lis[CSL Type(see below) Addre' " / Type Description _ �. U Unrestricted(up to 35,000 Cu.Ft. R Restricted 1&2 Family Dwelling gnaturc M Masonry Onl RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 $gust red Home Imp ent Contract HIC) > ( fit?/ HIC Company Name or HIC egrstran[Name Regisnanon Number c Addres � 45 _ d �plione Expimt:on Cat: . gnature Telephone SECTION 6:WORKERS'CO[vIPENSATION 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 ..........Zl-`� No........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE CONIPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT _ [•_ �/��yJ as Owner of the subject property hereby authorize �� _�e�/S.L—G.�— _to act on my behalf, in all matters I ,clariv,to wo,' Zhurize y thy•'hu;Hh,f4 pe.•r�it application. Sion ire Gv n_r _Date _ SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION [, - ------- ,as Owner or Authorized Agent hereby declare that the statements and infem. ation on the foregoing application are true and accurate,-to the best of my knowledge and behalf. Print Ni e nature of Owner or Aut ronze gent Date (Signed under the ains and penalties of perjury] 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(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 and Construction Supervisor Licensing(CSL)can be found in 780 C'MR Regulations 110.R6 and 110.R5, respectively. 2. When substantial work is planned, provide the informration below: Total Floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch) Gross living area(Sq. Ft.) 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 of cooling system Enclosed_ Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost"