10 BARR ST - BPA-14-1417 REMODEL BATH �
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� The Commonwealth of Massachusetts RE� �VED �S
_ °� Board of Building Regulations and Standazds , A� $g�
Massachusetts State Building Code, �so ctvut '. iNSPECT�� SALEM
Revised�ar13N11
Building Permit Application To Construct,Repair, Renovate Or Deq�p(js�� 0 A �
One-or Two-Fami[y Dwelling ����
This Section For Official Use Only
� — BuildingPermitNumber: Dat ,pplied:
�����J � �k/ � ala ��/
� Building Official(PrintName) Signature Date
' SECTION 1: SITE INFORMATION
`�_ 1.1 Prop Address: Sq�m m/d 1.2 Assessors Map&Parcel Numbers
y I O �c� S�•
/Y� 1.i a ls this an accepted s[reet?yes_� no_ Map Number Pazcel Number
, o �
t,, 1.3 Zoning Inforroation: 1.A Property Dimensions:
� Zoning Distric[ Proposed Use Lot Area(sq ft) Frontage(ft)
' 1.5 Buildiug Setbacks(ft)
Front Yard Side Yards Reaz Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.4Q§54) 1J Flood Zone Informatioo: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone? ,,I�
Public� Private❑ Check if yesO Municipal yv On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP�
2.1 Owner�of Record:
Laur�nee + u�G, g��le Sqler� /YI/� DI°t7D
Name(Piint) City,State,ZIP
lD Qac� S�', q78 795-73/9
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ OwnervOccupied ❑ Repairs(s) 1p Alteration(s) �'1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number ofUnits Other ❑ Specify:
BriefDescriptionofProposedWork2: Gaj� 6q�1�(�oorr�� Sro�all rieu/ wi��ia ano�p�umi � in5ulw��
D�aS}e�i f�12� inS{al� nE«/ �iKh,reS
SECTION 4: ESTIMATED CONSTRUCTION COS'PS
Item Estimated Costs: Q�cial Use Only
Labor and Materials
1.Building $ �9 r��� ,Tj� 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard CiTy/Town Applica[ion Fee
2. ElecVical $ I ZG� — ❑Total Project CosY�(ltem 6)x multiplier x
3.Plumbi�g $ ���� —� z, pther Fees: $
4.Mechanical (HVAC) $ L �� — List:
5.Mechanical (Fire $
Su ression Total All Fees: $
�` Check No. Check Amount: Cash AmounC
6.Total Project Cost: $ ��Cj�ll,� ❑paid in Full ❑ Outstanding Balance Due:
�a-�� C�����- �-� �, �2y
r • •
� .
SECTION 5: CONSTRUCTION SERVICES
5.1 Coostruction Supervisor License(CSL) �� � � �Z ISI�L�
� ,
S- lo2 �
�(�i��ja✓1 I USi LicenseNumber ExpirationDate
Name of CSL Holder
�j0 SGC`�y S'�'. List CSL Type(see below)
No.and Street Ty Description
, �a�bleheQ'� m� D���� U Unrestricted Buildin su to35,000cu.ft.
R ResVicted 1&2 Famil Dwellin
City/I'own,State,ZIP M Mason
. RC Roofin Coverin
WS Window and Sidin
�1q SF Solid Fuel Burning Appliances
78 t 63 I-q2oo C..YN1�St�n� Qe��i �nc:YCp/Y) I Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) f/ Tj JC 7.J� /
I l7 7
���q CopSt. �YtG _____- HICRegistrationNumber ExpvatwnDa[e
HIC om any Name or FIIC Registrant Name
�o pSe�s�� 5�. Chr�s��an��'eqa�q'u�c.cov✓�
{�u�b�c�o� M/-� oiaH� �81 631-9Zoo Em�;�aaa�ss
Ci !I'own,State,ZIP Tele hone
SECTION 6: WORKERS' COMPENSATION INSLiRANCE 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 Issuance of the building permit.
Signed Affidavit Attached? Yes ..........1� No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WI3EN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject properiy,hereby authorize ���q�q CoY�IfUCtiO�SYIC.
to act on my behalf, in all matters relative to work authorized by this building permit app�ication.
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 thnt all of the information
contained in this application is tru�and accurate[o the best of my knowledge and understanding.
cti�,�;an�T�g; �.D,--�— ��1��/�v
Prin[Owner's or Authorized Age 'ame(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,oc an owner who hires an unregistered contractor
(not registered in the Home Improvement ConVactor(HI:C)Program),will not have access to the acbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.eov/oca Information on the Construc[ion Supervisor License can be found at www.mass.eov/dps
2. When substantial work is planned,provide the infortnatiun below:
Total floor area(sq.ft.) (inchiding garage,finished basemenUattics,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 Projec[Square Footage"may be substituted for"To[al Project CosY'