0008 BARSTOW STREET - BPA-10-954 The Commonwealth of Massachusetts
WMBuilding
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR,7t'edition ALEM
ReOFS January Permit Application To Construct,Repair, Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
<<This S6efion For Official Use Only
Building Permit Number�� Applied:;
�j,,, y
Signature: �V'lA�^'� ` _ �O/I Y�L' _
Building Commissioned Inspector ofBuildmgs ..�- Date''.
SECTION 1 SITEINFORIYIATION
1.1 Pro erty dress: l[l 1.2 Assessors Map& Parcel Numbers
1.1a 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
1.6 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 ❑
Cheek ifyes❑
t SECTION : PROPERTY`OW 19R$HIPt
2.1 Ow er of Re o.d:
Y�
Name(Pn )� Address for Service: _
S ignatu& Telephone -
SECTION 3:DESCRIPTION OF PROPOSED Vf0 (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
:S 7 � Zi 6
SECTION 4: ESTIMATEWCONSTRUCTION COSTS
Item Estimated Costs: OffieiaL;Use Only
Labor and Materials y
1.Building $ 1.-Building Permit Fee: $ Indicate how'fee is determined:
2.Electrical $ r❑Standard,City/Town Application Fee
i❑Total-Project Cost'(Item'6)x-.multi lien x
3.Plumbing $ 1`17 ,$
4.Mechanical (HVAC) $ List _
5.Mechanical (Fire Suppression) $ Total All Fees:$ _
Check No,. heck, mount: Cash Amount:
6. Total Project Cost: $ 7�00 ❑paid in Full. ❑Outstanding Balance.Due:
$ECTION,`5_ CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) � �f�7 /. _( _ 0—
Mr a lf L C`\A r°6c-i License Number Expiration Date
Name of CSL-Holder List CSL Type(see below) L _
l /Sr� llti >(30 -I) PITS
Address T " ' Description r
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Si i1 M Mason Only
b 7�/ S 6�7 3 RC Residential Roofing Covering
Telephone WS- Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Re istere 1 H e I provement Contract r(HIC) Al
4
HIC CM Name or C Reg 1nt me Registration Number
J r _
Address elG� �i',i 'j 7k—AIJ— 3l Expiration Date
Signature Telephone
SECTION 6:.WORICERS'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 COMPLETEDWHEN':
OWNER'S AGENT`OR CONTRACTORR,APPLIES^FOR'BUIL-"DING�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.
Signature of Owner Date
SECTION-7bt OWNER'.ORs1UTHORIZEA'AGENT DECLARATION
as Owner,or Authorized Agent hereby declare
that the statements and infornatio on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
C� l
Print Name J� ,7
1ld
Signature of Owner or Authorized Age)it Date
Si ned under the vains and penaPp of -r'u
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.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
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"