12 BARR ST - BPA-2006-141 WINDOWS & DOOR 2g
The Commonwealth of Massachusetis
Board oi'Building Regulations and Sinndards CITY OF
\ Massachusetts State Building Code, 730 CMR Revised 1dEiu�l3g11
Building Permit Application To Construct,Repair, Renovate Or Demolish a
�- One-or Two-Fanny Duelling
1 This Section For Official Use Only
Building Per:ail Number: Date Apply a:
Building Official(Print Name) Sigmnum Date
SECTION 1:SITE INFORD,IATION
I Pro erty c Sk Address: 1.2 Assessors Alap &Parcel Numbers
���r�c
1.1 a Is this an accepted street?yes_ no Map Nutber Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
7.oning District Proposed Use Lot Area(sq t1) Frontage(N
1.5 Building Setbacks(ft)
Front Yard Side Yards Rorer Yard
Required Provided Required Provided Required Provided
l.6\)'nter Supply:(M.G.L e.40,§54) 1.7 Flood Zone Information: 1_3 Sewage Disposal System:
Public❑ Private❑ "Lone: _ Outside Fluod%one?
Check ii'yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY O\YNERSH IT'
2 1 Owner'of Record•
F�a..� Qa�� MR CAA ll7
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED N KC (check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ LAddition ❑
Demolition ❑ Accessory Bldg.❑ I Number of Units_ Other ❑ Speci6,:
Brief Description of Proposed Work: '_. W\,40 S .
'ti Z®of� StM.t. SI.'I-t_ a.nZ \ocr+k'.o.� r..o S kn.y kit 41 t�lw l��
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and M`aterials)
1.Building $ ` \ I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Ivlechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression) Total All Fees;$
qp Check No._Check Amount: Cash Amount:_
6.Total Project Cost: ❑Paid in Full ❑Outstanding Balance Due:
j
I L-0%
l
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) \15 7( l('
Name oT CSL 1V+f046 License Number Expiration Dale
older � )
IS plew_tt \f List CSL Typc(sce below) V
No. Street PIA u Type Description
Nov*6,I �p�",('O t�� D'��/t) U Unrestricted(Buildin u to 35,000 cu.ft.)
Cily/rowir,State,ZIP UL Afl t V V R Restricted IA2 Funnily Dwelling
M Masonry
RC pooling Covering
WS Window and Siding
S y SF Solid Fuel Burning Appliances
t Insulation
Telephone Email address D Demolition
5.2 R tered Home Improvement Contractor(HIC) /N 61
()wee �F p.t� HIC Registration Number Expiration DateHIC C zmi Nome or HIC Reg'strant Name
7
No.Cgnd Street Email address
Cityffowri,State ZIP Tcle hone ��
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.M.§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..........O No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR Am
FOR BUILDING PERMIT
/�I,as Owner of the subject property,hereby authorize m Min;
to act on my behalf,in all matters relative to work authorized by this building permit application.
PJ Owner's Name(Electronic Signature) Date
SECTION 7b:OykWW OWAV17HORIZED AGENT DECLARATION
By entering my name below,I her by attest rider a ins and penalties of perjury that all of the information
contained in this application is true d a rate t the est of my knowledge and understanding.
Print Owner's or Authorized Agent's Name( I Si ) Date
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 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/oce Information on the Construction Supervisor License can be found at www.mass. og v/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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"