5 BARNES CIR - BPA-2010-60 ROOF fhe Commonwealth of Massachusetts
Board of IIuilJing Regulations and Standards
CITY
,
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Massachusetts
State Building Cole, 780 MR, 7 ,edition OF SALF.M
RvvisrdJmnarrl•
�V Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Sectiop/Fiir Official QWQnly
IIuilJing Permit Numbe . ate App
signature:
w
Huilding Cummissioner/Infdector of Buildings I Date
SECTION 1: T ATION
1.1 Property Address: 1.2 Assesson Map& Parcel Numbers
I.I a Is this an accepted strect?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yard Rear Yard
Required Provided Required Provided Required Provided
1.6 Water apply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1 1.8 Sewage Disposal System:
Zone: Outside Flood Zone_ ? /
Public Private❑ Check if es❑ Municipal L3 On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2. Owner'ofI)e or an /j
EA
smelPri � N Address f"l � e'f��J� ��� LL�
Gd
Signet Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cbeck H that apply)
New Construction❑ Existing Building Owner-Occupied 01 Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.O Number of Units Other Specify:
Brief Description of Proposed Work-,
O
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OMCISI Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is deterjin0
2. Electrical S ❑Standard City/Town Application Fee
Total Project Coslr(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire Su «ssion) S `�/� Total All Fees:S O
Check No. Check Amount: Cash Amount:
6. Total Protect Cost: S 6 J/�O O Paid in Full O Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor ICSL)
License Number Fxpirafiun lyate
Name ul'C'SI.- I lulder I.ist C'SL Type(see below)
r)pe:j_-Descrip0on
Address U Unrestricted(up to 75,0W Cu.Ft.
R Restricted 132 Family Dwelling
Signature M I Masonry Only
RC I Residential Roofing Coverin
felepMme WS I Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name m IIIC Registrant Name Registration Number
Address Expiration Date
Signature 'relephome
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 2SC(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 ..........0 No...........0
SECTION 7a: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.
Sianature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
2 LA4 Owner r Awharized-AgenEhereby declare
that the statements and information oh the foregoing application are true an accurate,to the best of my knowledge and
behalf. O
Print Name 1U / ,
Signature of Ow er uthort gent Date ,F/
(Signedunder ains and penalties ofperjury)
NOTES:
1 / 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 W have access to the arbitration
program or guaranty fund under M.G.L.c. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I l0.R6 and I l0.R5, 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
). ..Total Project Syuare Footage'*may he substituted for"Total Project Cost"