BPA-17-34 HOME RENOVATION Sa
The Commonwealth of Massachusetts el.ZCEIVE EL H
�. �: Board of Building Regulations and Standards A� .'� T OF
Massachusetts State Building Code, 780 CMR SALEM
o L, �F�A� L` R�vis��Llar 2011
Building Permit Application To Construct,Repair, Renovate(PlAc D1ill a `�'av
One-or Two-Family Dwelling
p This Section For Official Use Only
�(\ Building Permit Number: Date Applied:
C)V /1}
Building Official(Print Name) Signature Date
i
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
13 /M,=,4z>0w .S'rMEE7—
L l a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
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:
At47Y.4Av F4656-144-We S446rA4, A4# 40197o
Name(Print) City,State,ZIP
13 titEA>ao W 67z-AnF T 661-3-02- -
V*' i n eo n eah
No.and Street Telephone Email Addr
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other la'Specify:
Brief Description of Proposed Work': 9/mrriyoe Dyrytoejizary a/XtLs, CF/U/SGS
s0,126k,000 A4_060tS gI Rewob'*t or S/D/IVG i R-06"
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
l.Building $ �ODD� 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x \
3.Plumbing $ 2. Other Fees:C$._ I NO
4.Mechanical (HVAC) $ List: l/ V
Ll
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
VH1 - tA(-\kL-eV 'VU '!�q C
. A �/'
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 0.5 SL-D 9937 0 /7
E P-C6 44.1 609.x,4� .04(pS779_ License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
��y c���T T e tion
P
pJ
U Unrestricted(Buildings u ft
to 35,000 cu. .
Sq,E4: 41976 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
�
�r SF Solid Fuel Burning Appliances
r/�r
/O -9St/yX UnI MNZOq, I Insulation
Telephone Email address /(Q¢ D Demolition
5.2 Registered Home Improvement Contractor(HIC)
�,[�uLJ nt rL'o 12E,!,+a✓We- DEmoL%riQ� /SS�a9
HIC Registration Number xpiration Date
IC Company Name or HIC Registrant Name
•S� /lI�/M1�i�PGi/r.QIJIIOLGL Cts I/.P/LJL�N_.
No.and Street Email address YI.Q f
Lc1�vy,
C�State,ZIP 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 .......... B' No........... ❑
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 ,L S AAJ /-. AbS M- ("Mam If-En)
to act on m beh�-a-l�f,jinQall matters relative to work authorized by this building permit application.
A - t
Print Owner's Name(Electronic Signature) ate
SECTION 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 is true and accurate to the best of my knowledge and understanding.
f� 111a 26/7
Print Owner's or Authorized Agent's Name(Electronic 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.eovioca Information on the Construction Supervisor License can be found at w�rv.mass.govidps
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"