9 BARR ST - BPA-16-701 REDO KITCHEN & 1ST FL BATH The Commonwealth of Massachusetta�
Board of Building Regulations and Stan ar CITY OF
Massachusetts State Building Cade, 780 CMR SALEM
��1 b d i� 21 A q � l8evised Mar 2011
Building Permit Application To Construct, Repair, Re tat rDemolish a
One-or Two-Family Dwelling
This Section For Official Use Only
•�-. Building Permit Number: Date pplied:
I Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
^� 1.1 Proyerty Address: 1.2 Assessors Map&Parcel Numbers
l ��r +•
I.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)
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:
Zone: _ Outside Flood Zone?
Public Private❑ Check if yes❑ Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 ,Onerot4f R�oecmordp sZ 6'1 y 7a
Name(Print) L City,State,ZIP
9 �au(/ J�
No.and Street V Telephone Email Address -
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ 1 Repairs(s) ❑ AI[eration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other Gr Specify: yuo
Brief Description of Proposed Work : 2 -t
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ I. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: &• D � / �L"CD
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 000 ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
cSd77 aa� 6
�ci�.tdeS —,Y- � License Number Expirati6n Date
Name of CSL Holder
/ List CSL Type(see below) _V
tit,-E
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
City/Town,
State Z R Restricted 1&2 Famil Dwelling
ity/Town,State,ZIP M Masonry
RC Roofing Covering
INS Window and Siding
"' ,` `/ SF Solid Fuel Burning Appliances
q20 17 q (—(/ D IV i17 9-G60Lts•�td^6.C�ra'1 1 Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
—9on w3e5 ) byJ l<nq HIC Registration Number ^xpi ion Date
HIC Company Name or HIC Registrant Name
,OR gak yf Jw/�zg�a�Y/
No.and Sir t Email address
A� �s h11� o/W7 91-IN-1aG4464'
�i /Town,Stat6,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 Issuanc of the building permit.
Signed Affidavit Attached? Yes.......... No...........❑
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 �r7.�Fe 4 7 4Va to act on my behalf,in all matters relative to work authorized by this building permit application.
A-156o e Z3A-,
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 true and accurate to the best of my knowledge and understanding.
Pnnt Owner's or Authorized Agent's Name(Electronic Signature) — T Date
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 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
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"may be substituted for"Total Project Cost"