33 BARR ST - BPA-15-512 INTERIOR DEMO, NEW KITCHEN The Commonwealth of Massachusetts
Board of Building Regulations and Standards 'ECE VEDCI
Massachusetts State Building Code,780 CMR VI I'L SFSW
Revised Mar 2011
Building Permit Application To Construct, Repair,Renovate Or Demolish a
FW
a
One-or Two-Family Dwelling A�
_ ( This Section For Official Use Only
N Building Permit Number: Date pplied:
a8
1 Building Ot)icial(Print Name) Signature Date
SECTION 1:SITE INFORMATION
Pzropeprt�y Ad�dreSN 1.2 Assessors Map&Parcel Numbers
' l.la 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 Yazd Side Yards Rear Yard
Required Provided Required Provided Required Provided
r1.6 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'
2.1 Owner'of Rec
Inime-_ rne1ia11 Sa1e.m , YY1f! tAddress
Name(Print) City,State,ZIP
�� barnNo.and Street Telephone EmaiSECTION 3:DESCRIPTION OF PROPOSED WORK''(check all that apNew Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ AlteratioDemolition ❑ Accessory Bldg. Number of Units Other ❑ Specify:
B ief DesT, ion of Proposed Work : O il I ✓1 N Te t1.7
.:v ✓boars
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official U
Labor and Materials a Use Only
1.Building $ L'Building Permit Pee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(item 6)x multiplies x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 50 A9D ❑Paid in Full O Outstanding Balance Due:
N -O . CFat,t_4zHo U S __> (. 11 ) 15
Cd�Pa"K,
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted uildin up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State,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 Issuance 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
to act on my behalf,in all matters relative to work authorized by this building permit application.
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.
Pi t Owner's or a gent's Name(Electronic Signature) 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
xvl niass.gov/oca Information on the Construction Supervisor License can be found at wtvvv.nmss.gov/dps
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"