41 BARSTOW ST - BPA-14-98 ROOF • II
The Comntomvcaltlt of Massachusetts
Board of Building Regulations and Standards SAL OF
M
( iLlassachusetts State Building Code, 730 C�IR J`\LB�I
Revised Alar 7U!!
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dive(ling
This Section For Official Use 0nl
Building Permit Number Dattl A pliedi
Budding Official(Print Name) Signature Date
SECTION I:SITElNFORrti(ATION
1.1 Property Add fegso (7 �II 2 1.1 Assessors t1lap& Parcel Numbers
l.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Informatlon: 1.4 Property Dimenslons:
Zoning District Proposed Use Lot Are*(sq it) Frontage(ft)
1.5 Building Setbacks(ft) 7f
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided '
1.6 Water Supply:(N.O.L c.40,§34) 1.1 Flood Zone Informations I.S Sewage Disposal System:
Public❑ Private❑' Zone: _ Outside Flooif
Zane? Municipal❑ On site disposal system
Check if es❑ P P y
SE`CTIONZ: PROPERTTO� OERStIMI
1.1 Ownertof c d:
Name(Print)
'' '-�- Lily,State�,rZl �m
No.and Street, ' Gy�e b Email Address
SECTION 3: DESCRIPTION OFPROPOSED.WORW'(checka that apply)
New Construction❑ 1 Existing Building Cl Owner-Occupied Cl I Repairs(s) Alter3tion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Works:
4
SECTION 4: STINLAMCO RUCTION COSTS-
Rem Estimated Costs: OfRdal Use Onl
Lahor and Materials Y
I. Building g I. Building Permit Fee.S Indicate how fee is determined:
?. Flectriad S CISl<andaid.City/fuwnApplication Fee.
❑'Cotat Project Costs(Item 6),e multiplier x
1. Plumbing i 1. Other Fats: S
t. \laehanie.:l (IIVAQ j List:.
\keh.wie.tl (Pin: 'ram—� I
1'ut.tl All Pces:.i
No. _Ghee c�lowunt:
I'n4tl Project "lit ) 17�� I ----
(]
SECTION 5: CONS'rMCTION SERVICES
5.1 Cunstruction Supervisor License(CSL)
L �— Grpir tiuu at
License Number
Lune of CSL I loldcr List CSL type(sae below)
-- Type Description
Nu. ;and Street U unrestricta Duildin s up to 3300 Co. tt.
R Rcstricmd 1A2 P;unilY Dwellin
Cityl rown,state, YIP VI Masonr
RC Rootin Covent
1VS 1Vinduw and Sidin
5F Solid Fuel hurting Appli;mcos
--C�I xfj 1 Insulation
Tale wne
Email uddrcas Uamolition
5.2 Registered Home In r vement Contractor(I
114 Registnuion umber Ex�n n U e
i C n y t u r l i
No 23
Email address
Ci / own ate IP ele hone
SECTIONS. WORKERS'COMPENSATION INSURANCE AFF[DAVIT(M.G.L.c. 152. 9 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 IssuancepMa building permit.
Signed Affidavit Attached? Yes .......... No........,..C3
S ECTIOIV 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize —P �9✓t
to act on Iny behalf, in all matters relative to work authorized by this building permit application.
Ma
Print Uwndr's Nnme(Electronic Slgnaturo)
SECTION 7h: UWNERt OR AUTPIORIZED:\GEN'T DECLARATION
By entering my name below, I hereby aft t der the pains and penalties of perjury that all of the information
contain in his appl ca ion is hero and ccur t o th ash ofmy knowledge and undemanding.
Print Ow ar s ur Authuriecd:\gent's N,u a( • actrunie iguaturc)
,NOTES:
I. ;\n Owner who obtains a building permit to do himher own work,ur un owner who hires an unregistered cuntractur
(nut registered in the Home Improvement Contractor(HIC) Program), will rro have access to the: itratiun
pro 'cun or guaranty tend under MAIL. c. 1 a2A. Other important inNrnatiun on the HIC Program can be found at
www anus+.ruv%oca information on the Construction Supervisor I.iccnsa can be found at www.nwsx.�v_+III
2. When sub;tanti;d work is planned,provido tha information below:
total tiour.trea Oki. 11.) __----- _(including gar:nge, finished basemenHattics,decks or punch)
tlro;; livinSarc.t(;,I. tt.) fl.nbintble room count _
?lnutbcroflirapl.tcc; _--_--—_.—
Numberofbcdrutins .-_--_--
Nwnhcr of h.t E .0 ns __--_----.
Vuuther of h.uhn+min; - _ --
f. :c of :; ;ya<nt
Puclo;eti ( )pert
� t ..I . i it I'n y •.t � pi u.: I t r;a" w.ty I+a ;nh,lini��,l t.