B-17-409 - 0006 BARTON STREET - Building Permit ,y
The Commonwealth of Mass
achs� "
Board of Building Regulations arid'Standards SIATLY OF
Massachusetts State Building Code,780 C : 3' Revised Mar 2011
Building Permit Application To Construct,RepairlReno-vate Or Demolish a
�— One-or Two-Family Dwelling
This Section For Official Use OnI
Building Permit Number .,., Date A e
$wldmg:Of.fictal(Pent Nairie) Signature Date
f SECTION. SITEINFORMATION, , k
1.1 Pro rt Address: 1.2 Assessors Map&Parcel Numbers
1.1a 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)
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 QRyNERSHIPI
2.1 O neri of Record:
sc den. AA A- 007 U
Name(Print) City,State,ZIP
'C -7Sy 'c�jSLI
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED;WORK?(check all that.apply);
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ iteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other • Specify: S.cJ
Brief Description of Proposed Work2: 56-! ;-.¢ ,,^c3 r :. d�i l c ✓
SECTION 4::ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item O,ffictal Use Only
Labor and Materials 3 ,K
1.Buldin $ 1 Building Permit Fee $n Indicate how fee is determined;
g S elm - i
0 Standard City/Town Application Fee'
2.Electrical $ ❑Totai-Project Costa(Item�°5)x tiultipler x
3.Plumbing $ 2 Other'Fee'§:'
4.Mechanical (HVAC) $ List
5.Mechanical (Fire $ ees:
Suppression Total All F
Check No...,.'- Cheek Amount" Cash Amount:
6. otal Project Cost: $ a 1 �^�U 17 Paid'in Fui1 ❑Outstanding AA*.0:1) e:
SECTION 5: CONSTRUCTION SERVICES
5.l Cut struction Supervisor Liccnse,(CSL) S �, S/c� /7
t
License Number Expiration Date
Name ofCSL Holder List CSL'fype(see below) AC 4 C•J S ,
Type' , . `. . Description ..
No.and Street
U Unrestricted(Buildings up
to 35,000 cu. It.
CL.-c c,,-e) aJ/-( U 3-Nc1 R Restricted 1&2 Farnily Dwelling
Cityfrown,State,ZIP M Masonry
RC Rooling Covenn
WS Window and Sidin
SF Solid Fuel Burning Appliances
60'-J> Sw Lf C 5, ( Q. o..,)•�-� I Insulation
Tele one Email address D Demolition
5.2 I egistered Home Improvement Contractor(HIC) 1( 5,G ti,Z 3 r 5 J�
A)I-( i:,�'4.e,%v r S HIC Registration Number Expiration Date
FIIC Co/n'puny Name or HIC Registrant Name (/� 1
No.and Street Email address
AC `t 3 -)
City/Town, State ZIP Telephone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M:G.L:.F.ISL 2$C(6)y,.
Workers Compensation Insurance affidavit must be c pleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuan of the building permit.
Signed Affidavit Attached? Yes ..........Cf No...........O
SECTION 74e OWNER AUTHORIZATIONTO BE.COMPLETED WHEN: :';'
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING.PERNI1T
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.
lit -7
Print Owner's qr_ 1u horized Agent's Name(Electron( Signature) Date
S: '
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 nu have access to the arbitration
program or guaranty fund underNI.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov!oca Information on the Construction Supervisor License can be found at www.nris.gnv'dus .
2. When substantial work is planned,provide the information below:
Total door area(sq. ft.) _(including garage,finished basement/attics,decks or porch)
Gross living area(sq.tt.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
'rype of cooling system Enclosed Opcn
3. "Total Project Square Footage"may be substituted for"Total Project Cost"