76 BARSTOW ST - BPA-13-485 ROOF - 7, --- hhe C'onunonsrcalth ul M;tssachusclls -
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code. 79U C'NIR "I t ,
H,,16, I1u -Il//
Building Permit Application To Construct, Rcpair. Renovate Or Demolish a
One- or Ttnl-Funlih Dwelling
This Section For Official Use Only
Building Permit Number: Date Ap md:
_ 3
Iluildiny Gllicial(print Mum) Signature Ua e
SECTION Ii SITE INFORMATION
L I Propert lddress: 1.2 Assessors Hap di Parc Numbers
B'arul0r..J S-\--
I.la Is thif an acce ted street?yes no Map Numlwr I'urcel Nunnh%r
I.J Zoning Informutlon: 1.4 Property Dimensions:
Coning District Imposed tl:w Lot Arca tsq II) Frontage(II)
1.5 Building Setbacks lR)
Front Yard Side Yards Rear Yard
Required Provided Required Pruvided Required Provided
1.6 Water Supply:(M.G.1.e.40,§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Public O Private O zone: _ Outside Flood Zone? Municipal O On site dispusul s)stem O
Chccklf vsC1
SECTION1: PROPERTY OWNERSHIP'
3.1 Wall`Record:
A 'I .,g eC.A �n c�n e �A V rn c>A-o !V, � O.3ia7 7
Name(Print) City.Statu.ZIP
60389S4v3c'
No.and Street relephune Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Buildin caner-Occupied ❑ Repairs(s Iterationts) O 1 Addition a
Dentolition O Accessory Bldg. ❑ 1 Number of Units_ I Other O .Specify:
Brief Description of Proposed Work': OLL o
SECTION J: ESTLNATED CONSTRUCTION COSTS
ltcns Estintafed Costs: Oflicial Use Only
(Labur and .\Lmerials)
I Building S 21 1. Building Permit Fee: S Indicate how tee is determined:
F:Iceir cal S O Standard City.?uwn Application Fee
❑Total Project C'oslt I Item 6)x multiplier _.. x
i ) I'lunihing 5 ?. Other Fear. S- ------ � .
1. \kch.wical ill\ \('1 S LisC._
—
�u .rniiiont S final .\IlFces: S�____---- . ._
p ('O heck \o. ( hec);Antoum: l',uh \uununt:
o Total Project Cost: i �s 3 O D� P,nid in Full ❑Otostanding Hal.mce Due:
SECTIONS: C'ONSTRUC"PION SERVICES
5.1 ConstructiunSupcnisorLicenseI('St.) y_(
`A � I tars.¢ Nunlhcr I'.pvulion Dale
N,unc ol'l'SI. I Inldar
I Ist CSI. 1)Ix Ise¢helulsl _ _
r,P: nexriplion ..
No. and Slrccl
y'� / U 14trcstrideJ I IIIu Win s li l0 1s,IlUn ca It.l
��A���Y Mom_ SJ 1 9__b C?__ R Ra,IricicJ Idl•2 f.lmil I]ttcllin
C'40'oan,AGnc./IP ..\I Mason
NC Rtx'1111 Cu. init
..._. A's window.uid sidillit
SF Solid Fact Ourning Appliances
I 1 lasulution
1'ele hone Ilmail aJJmsr D Ihnlulitiun
5.2 Registered llume Improvement Contractor(HIC) 1 D O,3 ( ( '(—2
G lbo Lk—r r III(:Rcglstratiun Number F\pirllion Dale
I IIC Contpan) Nanlc or I IIC Itegisumn Nanw -
� �tJ Sueel ' Email address
Tri� b ELoY(�1� D � q cry
City/Town. State ZIP role hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e. 132.1 23C(6))
Workers Compensation Insurance affldavit must be completed and submitted with this application. Failure to provide
this alfldavit will result in the denial of the Issuance of the building permit.
Signed Affldavit Attached? Yes ..........o No...........t]
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 matters relative to work authorized by this building permit application.
Print Uwner's Nmne(Elcctrunic 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.
Print Unner's nr udnlrireJ.\gal Nanw I likctrunic Sign;lulro) Datc
NOTES:
I. .%n Osvner who obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor
Utot registered in the Hume Improvement Contractor(HICI Program), will t have access to the arbitration
program ur guar my t'und under M.G.L.c. 141A. Other important information on the HIC Program can be litund at
1 htforntmion on the Construction Supervisor License can be found at 1,It„ it,i,: g;-t ,ql,
_2 \\'hen substanlial twrk is planned, pros ide the information below:
total flour area I sy tt.l - 1 including garage, linished basement aUics. Jerks or porclrt
Gross lis iog area 1 sy. it.l. . ilabilable roust cuunt
\anther of lircploces Number ol'hcdroonts
\umlher of hathrvonls \umbcr of half h;uhs
l I\pc of heating s)steal . . \unlhcr of decks, porches
I\{'col'c,'olingsaeln I'ncln,cJ Open
i
1JLd I'roject $,Illllre 111U114e 111;1\ he UI11AlI111Cd lof IoLII PfUjeCl Clhl-