4 BARTON ST - BPA-12-607 RPR WATER DAMAGE ncc Commonwealth ol•Massachusells
1� '� V Board of*Building Regulationsand Standards CI'I'1.OF
C ( J9 Massachtuclts State Building Code. 7S❑C'MR SALEM
Lv ReVi.rrJ.I dtr-'11//
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-urTm•u-bamils Dmcllin•%t
This Section For Official Use Only
Building Permit Number: — pate AP lied;
Building Official(Print Mune) 9gn• I ale
SECTION I:SITE VOORNIATION
1.1 Property Add ess: 1.2 Assessors Map di Parcel Numbers
1.la Is this an acre led street? es no Map Number Purcell Numbcr
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District I'ropo,cd U u Lot Area(sq 11) Frontage ill)
1.5 Building Setbacks(R)
Front Yard Side Yards
Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c.JU.§Sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
14tblic❑ Private❑ Zone: _ Outside Flood Zone?
Check if vs0 Municipal O On site disposal s)stcm ❑
SECTION2: PROPERTY OWN]
2 Owner'of Record:
AIL A( C I A,\1ATT 1 5ALe" M
N;uno(Print) City.State.l.IP
tike pJ �iR �Te�le phone 1 �AII5 t sr r
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ I Osvner•Occupied ❑ 1 Repairsis) ❑ Alteration(s) ❑ Addition O
Demolition ❑ Accessory Bidg.❑ JNumber of Units_ Vother ❑ Speedy:
Brief Description of Proposed Work':
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and \laterials) 011iclal Use Only
I. Building S I. Building Permit Fee:$ Indicate how fee is determined:
lilcetrical $ ❑Standard CityiTown Application Fee
O Total Project Cost'(hem 6)x multiplier _ _—x
i. Plumbing S , Other Fees: S _
4—mcchanical III\'.\(l S Lisl:
' 3. \Icdlanical (Fire ---_-- ---------- -- ---- - -
`wiressionl
C,
Check No. ('hcek Anrouut: uh \m,nml:
o Total Project Cost: S ❑Paid in Full ❑OulsrmJing Bal:mcc Duc:
SE(A IONS: CONSFRUcrIONSFIRVI(TS
5.1 Construction Supen isor License(CSL)
1�\piratioii Date
I icemse Number
Ntimeol'(S1. 11olkler listc-SI. I.Nrw(see
I')PC Description
uo it)35.000 Cu. 11.)
No. and rev( R Retrivied�kM%%el ling
Cil�i town.State./111 Slason
RC K,xillnit Covering
\k S Windim imd Siding
SF solid Fuel Fluming Appliances
I Insulmiun
re'i D 10d
felcylione Email address
ro I IC)
Demolition
5.2 Registered Home Improveme"nt Contractor(HIC) F\piralioi Date
111C Compin) Name or 111C Registrant Name
No.and Street Email address
City/Town.state,ZIP roe hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.J 2SC(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..........a No...........0 —
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1.as Owner of the subject property,hereby authorize
vl W, half,in all matt r"s relative to work�authorized authorized this building permit applicatio
t cto my Z /
0"", t Slit Date
Signature)
t 0%wiver's ne(Electrunic- ignature
SECTION 7b:OWNEWOR 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 0%%net'i or Name(FIcctronic Sigimitirc) Dale
NOTES:
I 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 1d) have access to the arbitration
program or guaranly fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
n be round at 111,1,;
i information an the Construction Supervisor License ci
2 \ii Ile t,11111al
2. \k lien substantial work is planned,provide the hifurnillion below:
totala I tl"orare' ttics.decks or porch�
Otal t1oor area n.) I including garage. finished basement i
Gross living area t sq. 11.) ...... Habitable room count
\wnber o I'll relilat;es --- Ntlliiher ol'bedrooms
Number tit bathrooms \11111licr ofliall,hathi
Numlivro(decks, porches
1"indosed
1. ,foi.il 11roic,vt Square Foolilge-jiiaN he substituted tlor 1o(al Project Cost-