B-19-21 - 0045 BARR STREET - Building Permit The Commonwealth of Massachusetts
i IR U—il Board of Building Regulations and Standards' -.CITY OF
'J Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,RenoveW br- ffo%sA,
One-or Two-Family Dwelling This Section For Official Use Orily
.........
Building Ofcial(Print Name)
Signature SECTION;1. SITE
,
INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
I'll
L l a Is his 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 0 Private 13 Zone: Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yesO
SECTION 2 ;:PROPERTY ClWNER51IIP
................
2.1 Owner'of Record:
CAS2W
Name(Print) City,State,ZIP
qeS 11sr
No.and Street Telephone Email Address
SECTION 3 DESCRIF:TION OF PROPOSED WORKZ(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 11 Alteration(s) 0 Addition 13
Demolition 0 Accessory Bldg. 0 1 Number of Units--I Other( Specify: KI
Brief Description of Proposed Work2:
SECTION 4. :;ESTIMATED CONSTRUCTION COSTS:;:
Estimated Costs:
Item 1 011-
(Labor and Materials)
1.Building $ LLL., dlc*e w fee is determined
b.
�O,Stattadt,&Cit 4. A fi t*' Fee
y Vowni pp,ica i.9n.
2.Electrical, $
0 X:hilllti H
3:vie ��6)� 76tal:p t o -
........ C6st...
. 2;� Other 3.Plumbing
4.Mechanical (HVAQ $
5.Mechanical (Fire
Suppression Total
...........
Check: q Cheek A t Cash Amount
6.Total Project Cost: $
❑Outstanding Balance Due:
���uQ 6b 1�
I Construction Supervisor.License(CSL) `\ a�
C 1- ba iG p
License Number Ex irttion ate
ame o C o dcr
�. List CSL Type(see below),eN V
� — — t a. nd Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
_��o �`C l.L R Restricted 1&2 Family Dwelling
City/Town,State,LIP Im N4asonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home improvement Contractor(HIC)
( _ HiC Registration dumber rxpirajion Date
C o ty�Name or HiC eR istrant Name
an Street ., C _ Email address
ii /Town,Stal:ejrp Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(IM.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............0
SECTION 7a:OWN A THORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRA P S:FOB BUILDI 'G-RERMiT
I,as Owner of the subject property,hereby author ze
to act on my behalf,in all matters relative to wor author'ze �s buil to�permit application.
Print Owner's Name(Electronic Signature) bate
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 lily knoxvledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) YDate
NOTES:
t. 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 find under M.G.L.c. 142A.Other important information on the HIC Program can be found at "
information on the Construction Supervisor License can,be found at +a w",.m ss,govicl s
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished bascrnentlattics,decks or porch) I
Gross living area(sq. ft.) Habitable room count I Number of fireplaces Number of bedrooms i
Number of bathrooms Number of:halfibatlts ,
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"