44 BARSTOW ST - BPA-13-861 SHINGLE PART OF HOUSE !� The Coin moinvealth of Massachusetts
1 rrr L Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code 730 CNIR Sdkfar
1 Revised tifarALEM 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Divelling
this Section For Official Use Only
Building Permit Numbers Date 'replied:`,
vtyw,.: tiGrr ��.u1f)
Building Official(Print Name) .+.Signature_ -. Date
SECTION 1:SITE INFORIVIATION.
hi Property, t r s 1.2 Assessors Map& Parcel Numbers
1.1 a 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 Yard 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 ❑
Check if es❑
Q R rd
SECTION2:, PROP.ERTYOWNERSHIPL
2.1�'YEt2 Wl�cct� :n�
Nam (P in City,State,ZIP
No, and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK"(check all that apply)
New Construction Cl Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Pro osed Work": Ott)
�} �6
SECTION 4: ESTENIA.TED CONSTRUCTION COSTS-
[rem Estimated Costs: Official Use Only.
Labor and Materials
1. Building S pv I. Building.Permit Fee S Indicate how fee is determined:
Standard.City/Town Application Fee
2. Electrical S
❑Totat Project Cost (Item 6)x multiplier x
3. Plumbing S 2- Other Fees: S j
1. Mechanical (IIVAQ S List:_
i. :Mcchanical (Firs S
Suppression) Coal :\II Fces: .S_
n 1'nt:tl Pro Cult S l heck No. _Check Amount: Cash Amount.
_
ct ❑ Paid in lull ❑ Outstanding tS dtncc I)u
,
SECTION 5: CONS'rltucr[ON SERVICE'S
5.I Construction Supervisor License(CSL)
aVD C ! l — CSl'1�v 3
- --
License Number Gspir«iun ate
Name of CS/L�I/lolder List CSL Type(see below)
Typo Description
No. and Street
rt A e ,(�G,� U Unrestricted 2 Faintly
(Buildings s u to Dwelling
Co. tt.
_ IV r l R Restricted I,4e2 Fnmil Dwallin
Ci wn, Stat IP L%,I iMasonr
RC Roofing Covering
\VS Window and Siding
SF Solid Fuel Burning Appliances
1
L Insulation
I'ele hung Email address D Demolition
Ina rove tent Contractor HIC)
5.2 Registered H e p ( Sip
771 f:cll1
sr6Alir FI C Registration Number E.rpu'anon Date
11 Xmpany ft or I[IC giyjt)nt N one
No. Sir _-f7 Zf 2�e.rJ Email address
City/Town, State, ZIP IV Iele hone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(VI.G.L. c. 152. 1 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 .......... 13 No ........... ❑
SECTION 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
to act on my behalf, in all [natters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7h: OWNEW OR AUTHORIZED AGENT DECLARATION
13y.entering my name beI w, I hereby attest under the pains and penalties of perjury that all of the information
o inM' ta teat n i true and accurate to the best of my knowledge and understanding.
I inn vner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. ;\n Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor .
(nut registered in the Hume Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty find under M.G.L. c. 112A. Other important information on the HIC Program can be found at
www.ncusovioca Information on the Construction Supervisor License can be found at krw•w.ma.;.,.�u� (L
2. When substantial work is planned,provide the information below:
rota) floor area(sq. R.) (including garage, finished basement attics, decks or pinch)
Gros; living area (sy. ft.) Ribitablc room count
Nnniberoftirepluccs ----- Number of bedrooms _---_----- —
-
Numberothathrooms Numberofhalt'baths — ---
I'cpu _—__--
I`.pe of Cooling +yaeut ..- _ . _-_ -- --, Fuclo;ed Open ------___----
j�Ct It.urc Fart i e" ni,ty he ,nh,titI I t a "'I'„tit I'rujed