0017 BARTON STREET - BPA 17-120 ROOFING The Commonwealth of Massachtiseiti ' ' ;,111-N -
�- I' Board of Building Regulations and Standards CITY OF
1 ,\ / Massachusetts State Building Code,3PIt 214 A SALEM
� Revised Mar 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: FFate Applied:
i, 7 i
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 PropeAddr,s� 1.2 Assessors Map&Parcel Numbers
µ�
I� /S�i on 5
Lla Is this an accepted street?yes-x— 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'
RO„ v►lnr
er'a Re o df
Rz
Na (Print) City,State,ZIP
Pand Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other Specify: o
Brief Description of Proposed WorkZ: 1 11
;Os-
SECTION
P ,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 Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 9-*1 ' ❑Paid in Full ❑Outstanding Balance Due:
(-tat t_lro To (Z4 .C. '24 M
SECTION 5: CONSTRUCTION SERVICES
5.1 Constructio Supervisor License(CSL)
License Number Expiration Date
Name of CSL Hol er P
� � List CSL Type(see below)
No.and Street TYPe Description
7 U Unrestricted(Buildingsu to 35,000 cu.ft.)
I `� v R Restricted 1&2 Family Dwelling
City/Town,S e,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
I� SF Solid Fuel Burning Appliances
/)0
1J 1 Insulation
Telephone Email address D Demolition
5.2 Registe Improvement Contractor(HIC) 1,✓�L/�� G��
HIC Registratio Number xpiration Date
HIC CompanyLy N e o. C R istrant Name
ham, ,fnh
No.and S eet U/� C �/)�. �l Email address
lih
citrrowh,State,ZIP �l 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...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIP IUOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize G ;�4
to act on my behalf,i all matters relative to work authorized by this building permit application.
4 � 4
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I her y attest under the pains and penalties of perjury that all of the information
contained in this ap 'cati is a and accurate to the best of my knowledge and understanding.
� n
P n wner's or u 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 M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.go,,/oca Information on the Construction Supervisor License can be found at w,,vw.mass.g_ov/dps
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 halfibaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
�,C
3. "Total Project Square Footage"maybe substituted for"Total Project Cost" �