87 BARSTOW - BPA-14-874 REROOF The Commonwealth of Massachusetts RECEIVED
Board of Building Regulations and St�,p�
815L k?ZONAL $ERVI ES cAL OF
p �y Massachusetts State Building Code,7 SALEM
QQ vise'TYd Mar 201!
Building Permit Application To Construct, Repair, Rent8*% �iboiA N
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Dale Applied:
Building Official(Print Name) Signature WDe
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
¢g7SSdoa) A
I.la Is this an accepted street?yes no_ Map Number Parcel Number
1.3 'Coning Information: 1.4 Property Dimensions:
%onimg District Proposed Use - _ Lot Area(sq 11)-- Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
E!HEtts
Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: LS Sewage Disposal System:
Public❑ Private❑ lone: _ Outside Flood Zone?
Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSt11Pr
2.1 Owner of Record:
Numpc--(—�� -I'�ri�nt) � City,State,ZIP
_7` �.- 1
No.and Slroet Cele hone
p Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ ,,AI-�ion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units__ Other Specify:��
Brief Description of Proposed Work: T
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
I. Building $ I. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costs(Item 6)x multiplier x
3. Plumbing $
2. Other Fees: $
4. Mechanical (FIVAC) $ List:
�. Mechanical (Fire
Su ression $ Total All Fees: $_
Check No. Check Amount: Cash Amount:
G. Total Project Cost: $ U ❑ paid in Full ❑Outstanding Balance Due:
6`i3-d y
w �
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction.Supi6i'sor"License(CSL)
)
CS -n�o
��ez U(� L%fQ ?21at License Number Expiration Date
dame of CSL EToitler
y - t A, d List CSL Type(see below)
�l7CLiI /L ( T 1
No.and Street Description
yn�r IG ] � c,? g�:
Unrestricted(Buildings u to 35,000 cu.ft.)
Y �! / CC Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
��r SF Solid Fuel Bunting Appliances
�X D7 7b I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
Alb4-ioVtG��wii- - �� d5� l7slk� r6
HIC Registration Number Expiration Date
H-on?ep 'N` am�r I-11� Registrant Name
N 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 .........X 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 Nett-(bhak Agjlqwkitf 'I&—q AA
to act y behalf,in all matters relative[ work authorized by this building permit application.
Y Print ier's NanLiltlectrohic Signature) Date
SECTION 7b:OWNEW 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 tr a andlactate to the best of my knowledge and understanding. y
Prin & r(er's or6A6t orized Agent'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
www.mass.¢ov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
2. When substantial work is planned, provide the information below:
Total floor 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"may be substituted for"Total Project Cost"