B-17-876 - 0023 BARR STREET - Building Permit $ s � crtsLl
0
The Commonwealth of Massachusetts
® Board of Building Regulations and Standards FOR
Massachusetts State Building Code,780 CMR MUNICIPALITY
USE
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
Tb�s Section For 0ffic�a1.LTse,Qn1 y.
Building Peimit Number ,
Buildmg Official(Pent Name) ¢}^ x Signature
SECTION 1 SITE,INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 7" ;
1 RA-
1.1 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) t1't
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 Kwnerl of Record: Q
Name(Print) City,State,ZIP
43a `//3 01-J-1 Y a6yg aA^0 V Q fW c rr--
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.❑ Number of Units Other ❑ Specify:
Brief Descri tion of Proposed Wor z:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item (Labor
Costs: Official Use Only
Labor and Materials
1.Building $_. �' o a C7 1. Building Permit Fee:$S3 0% Indicate how feeds determined:
2.Electrical $ .❑Standard City/Town Application Fee
❑Total Project'Cost (Item 6)x multiplier x
3.Plumbing $ v Cl O 2. Other Fees: $
4.Mechanical (HVAC) $ -ZjV(7 List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ t7 C/ (7 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5 ,CONSTRUCTION SERVICES,
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
0 SO4 TYpeS Descnphon
No.and Street
U Unrestricted(Buildings up to 35,000 cu.ft.
S r 04 pt-oq- Restricted 1&2 Family Dwelling
ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registere Home l�nprovc�ntractor(HIC)
C,V HIC Registration Number Expiration Date
HIC Company Name or HIC RegistrVt Name n
U V2 �Q'It4 i C CO—
No5and Street s ;A n C 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...........❑
`SECTION ii-OWNER AUTHORIZATION TO BE COMPLETED WHEN -
OWNER'S AGENT,OR CONTRACTOR APPLIES FOR BUILDING PERMIT .
I,as Owner of the subject property,hereby authorize
to 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:OWNER'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 t and accurat est of my knowledge and understanding.
Print Owner's or uthorized Agent's Name(Electro 'c Signature) Date
1. An Owner who obtains a building permit to do his er 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.gov/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 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"
I