B-17-775 - 0020 BARNES CIRCLE - Building Permit C K 11 -7(o
�, The Commonwealth of Massachusetts-I...�,��# { ���. FOR
W Board of Building Regulations and Standards MUNICIPALITY
Massachusetts State Building Code,780 MR USE
Buildin Permit Application To Construct Repair, y 1 1 1 'P 2' ed Mar 2 1
g pp p ,Renovate �emolish a is a 0 1
One-or Two-Family Dwelling
This Section For Offcal Use,Only
1 Butld_tng Permit Number Date/phed:
$uildmg Official(Pant Name) Signature Date
SECTION 1:SITE INFORMATION
l.lr e :
.,� p �'Address: �p 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes no Map Number Parcel Number
Zoning Information: 1.4 roperty Dimensions:
Zoning ' trict Proposed Use Lot Area 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?
•
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION'2 PROPERTY OWNERSHIP' q,
2.1 O ner'of Recor S�� o�n �S�1J�' ,ALVA MA 0) l�J
ame(Print) City,State,ZIP
_�o FA) G� ��8. $8U.a'%
No.and 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.❑ I Number of Units Other ❑ Specify:
Brief Description of Proposed Work2:
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 $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6. tal Project Cost: $ �� ❑Paid in Full ❑Outstanding Balance Due:
,KL ZZ Z
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
r License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition ti `
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,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 .....:....❑ No...........O
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT:OR.CONTRACTOR APPLIES FOR BUILDING PERMIT
"as, ner of the subject property,hereby authorize
to act on b1e}haa f,in all matters relative to work au d by this building permit application.
Print O is Name(Electr• is Signature) Date
SECTION 7b:OWNEIFOR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
co tarred in this appl' ation is true and accurate tot the best of my knowledge and understanding.
Print Owner's r Authorized Agent's Name(Electroni ignature) Date
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. og v/oca Information on the Construction Supervisor License can be found at www.mass.eov/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"may be substituted for"Total Project Cost"