0027 MARION ROAD - BPA-15-997 4
- Gl«17 3 $3,G 7-
The Commonwealth of Massachus tts
Board of Building Regulatio Fdar�c E D CITY OF
Massachusetts State Building dde, `C1VIR S E R`> i C E S S
Revisedd Mar 2011
Building Permit Application To Construct,Req 1' � oyaf(�r D flnf sh a
One-or Two-Family Dwe7lling
This Section For Official Use Only
a Building Permit Number: Date Applied:
i Is
Building Official(Print Name) Signature 00 Date
ECTION 1: SITE INFORMATION
1.1 Property Address mQ 1.2 Assessors Map&Parcel Numbers
1.la Is this an accepted street?yes_ nc Map Number Parcel Number
1J 1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
00 Front Yard Side Yards Rear Yard
Cr' Required Provided Required Provided Required Provided
6 OF,
l '
141.6 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 ❑
1 Check if yes❑
n Lo SECTION 2: PROPERTY OWNS HIP'
O 2. wner'of Recor
x(LlC�K OlQr\T: �Df)011) Q -I
Nhme(Print) City,State,ZIP
No.and Street Telephone Email Address
ISECTION 3:DESCRIPTION OF PROPOSED WORIe(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Workz:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $3c� 00D OD 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: $`j`ar .u/t o ) ❑paid in Full ❑ Outstanding Balance Due:
Z pEYw t r-� Tr, MIuD �
it
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervis r ' ense(CSL) S t � 7
JQ r 0 i License Number Expiration Da e
N e f CS Holder
J� C — D_ List CSL Type(see below)
o. Street J iI Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
M MasonryRestricted 1&2 FamilyDwelling
C7tyo ,StatZIP j
RC Roofing Covering
WS Window and Siding
7 Fyn 3 y� SF Solid Fuel Burning Appliances
I
�Q a, Insulation
Telephone Email address D Demolition
5. Registered nine 1rove t Cntractor(HIC) 2 2�5/
�EpA �
In HIC Registration Number
a y
xpiration Date
HI Company Name or HIC Registrant Name j
��rn�l'Isl,ui�1(�
N 4<. d Stree [,�^CJ J /I p.-y� Email address
Ct wn, State ZIP 6 Telephone
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.........Olf-
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_
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
contained in this application is true an accurate to the best of my knowledge and understanding.
Prin Owner's or AuihoNzed Agents (Elect6ilic Signature) Date
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 can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass. og v/dns
2. When substantial work is planned,provide the information below:
Total floor 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"maybe substituted for"Total Project Cost"