18 BARCELONA AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
A Board of Building Regulations and Standards Town of
�j Massachusetts State Building Code, 780 CMR, 716 edition
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Family Divelling
Section For Official Use Only
Building Permit Number Date Applied: ' Z. . O
Signature: ' s 'Zlv a
^ Building CoRrK issioner/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
Ppro yrty Address: * 1.2 Assessors Map& Parcel Numbers
I.la IS this in accepted street?yes i/ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: ^°
Zoning District Proposed Use Lot Area(sq R) 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'
lElectrical
ner'of Reco d:
cr l� �Git) Address for Sery Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
nstruction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ion ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
scription of Proposed Workz:
C'eiSECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Labor and Materialsg $ I. Building Permit Fee: $ Indicate how fee is determined:cal $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier
3. Plumbing $ 2. Other Fees: $ , /�\)
4. Mechanical (HVAC) $ List: / �1
5. Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6. To[al Project Cost: $ �(�� 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expimuon Date
Npmc of CSL- Helder List CSL Type(see below)
Type Description
Address U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted I&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF ing Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 79: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 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.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1 ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
,behalf
Iqa Zri c a �' f�c�
Print e
ignature of Owner or Authorized Agent Date
Si ned under the ains and enalties of eru
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 nor have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I I O.RS, respectively.
2. When substantial work is planned, provide the information below:
Total floors 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" _