BPA-17-265 REDO BATHRM The Commonwealth ofMassachuseits�,F C I lilz' ALSER� �3
OF
Board of Building Regulations and Standards CITY M
W Massachusetts State Building Code,780 CMR SALEM
�'� t,pp
12 F7 2: (�ised Mar 2011
Building Permit Application To Construct,Repair,Ren a e r emolish a
( One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date pplied:
Building Official(Print Name) Signature Date
SECTION 1 SITE INFORMATION
1.1 P per Address: 1.2 Assessors Map&Parcel Numbers
/�'L"herr f
1 1 l.la Is this an accepted street?yes no Map Number Parcel Number
�1 1.3 Zoning Information. 1.4 Property D nsions:
Zoning District Proposed se Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards az Yazd
Required Provided Ikequired Provided RequiredProvided
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 OWNERSIIIP'
2.1 O ofR� de : Gp
n{ G /90
Name(Print) City,State,ZIP
J9 OwVYV A// ,+,r& 0/79966665 ,c,,7iPalqne/C'? t,'�Ln .C64"\
No.and Street I Telephone —1 Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) Erl Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed W�f k2:
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:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. Cheek Amount: Cash Amount:
6. tal Project Cost: $ l"�-QD v - ❑Paid in Full ❑Outstanding Balance Due:
L L.e:10 W H U
4
J
SECTION 5: CONS'TRUCT'ION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiation Urate
Name of CSL Holder List CSL Type(see below)
Type Description
No.and Street
U Unrestricted(Buildings tip to 35,000 cu. It.
R Restricted 1&2 Family Dwelling
Citylfown,State,ZIP N1 Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or NIC Registrant Name
No.and Street Email address
Ci /Town State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G;L e.152.g 2$C(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 Isittance of the building permit.
Signed Affidavit Attached? Yes..........O No...........13
SECTION 7a:.OWNER AUTHORIZATION TO BE COMPLETED,WHEN:
OWNER'S AGENT OR CONTRACTOR APPLIES`FOR BUILDING..PERMIT
1,as Owner of the subject property,hereby authorize -
t9 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: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.Q��a ej,"
14
Print Own 's or Authorized Agent's Name(Elcctroni ig,tature) Date
NOT
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
%v%vrv.rnass.gov'oca information on the Construction Supervisor License can be found at tvww.mass.-oe!das
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
,lumber of bathrooms Number of half/baths
Type of heating system Number of decks/porches
'type of cooling system Enclosed Open
3. "Tota) Project Square Footage"may be substituted t'or"Total Project Cost"