BPA-17-43 PER. APP 3RD FL BATHROOM REMODEL 33 t2- _
"the Commonwealth of Massachusetts
i Board of Building Regulations and Standars ( 'f r .(,:ITY OF
q Massachusetts State Building Code, 730 CMR " `SALENI
t tt�� Revised Nur 2011
Building Permit Application To Construct, Repair, Renovate Di"Detttllis�a E12
One-or Two-Family Dwelling
1 This Section For Official Use Only
Building Permit Number. Date.Applied:
Building 0fficial(Print Name) Signature Date
SECTION I:SITE INFORNIATION'
LI P operty Adpress: t.2 Assessors Map&Parcel Numbers
I.I a Is this an accepted street9 yes no blap Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
"Luning District Proposed Use Lot Area(sq ft) Frontage(It)
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 esO
SECTION 2: PROPERTYOWNERSHiP4
2. Own of Re c rd• • w ft_ b__� ��'\J Q `
NN me(Print�j i A City,State,ZIP
�
4' _ ., " �24--f2=ZLl6 Z CDw Q.
No.and Street Telephone Email A ress
SECTION 3:DESCRIPTION OF PROPOSED WORK;(check all that apply)
New Construction❑ Existing Building'. Owner-Occupied ❑ Repairs(s) 13Alteration(s) Addition O
Demolition 13 Accessory Bldg.13 Number of Units Pther ❑ S cify:
Brief Descripgn of Proppsed 1 rk': o
SECTION 4: ESTENIATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I Building S 00D1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S /000 ❑Total Project Cost(Item 6)x multiplier x
3. Plumbing S ®()0 2. Other Fees: S �—
l.�\.lechanical (FIVAC) S List
5.,\lechanical (Fire
Suppression) S ' "focal All Fees:S
Check No. Check Amount: Cash Amount:
6.Total Project Cost: ��� ❑Paid in Full ❑Outstanding Balance Due:
I/ e_t, f- f\,L_t-D -1-0- 1'-I _ ,
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.,md Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 F,.unit Dwelling
City/town,State,ZIP M Masonry
RC Roofing Covering
WS I Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address I D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IIIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /Town State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I»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 Is§uance of the building permit.
Signed Affidavit Attached? Yes..........❑ No...........0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED.WHEN:;
OWNER'S AGENT OR CONTRACT 0RAPPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize _
t11a9rqnM behalf,in all mjVqrs relative to work authorized by this building permit application.
P Owner's NaAie(Electronic ignature) Vate
SECTION 7b:OWNEW ORAUTHORIZED AGENT DECLARATION
By entering my name below,l 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.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 NI.G.L.c. 142A.Other important information on the HIC Program can be found at
%wvw.mass.cov!oca Information on the Construction Supervisor License can be found at vvvv%v.n1ass.3ov lnS
2. When substantial work is planned,provide the information below:
'notal tloor 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 halkbaths
Type of heating system Number of decks/porches
'rype of cooling system Enclosed Open
3. `Tota) Project Square Foota;e"may be substituted for"Total Project Cost"