12 BARTON ST - BPA-13-673 UPDATE KITCHEN & INTERIOR RPRS =� The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
UU, Revised Afar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Tivo-Family Dwelling
This Sectton.For Official Use Only
Building Permit Number: Daf hed>
AV
wilding official(Print Name) 'Signature - . Date.
SECTION 1:SITE INFORNLATION
1.1 ProRr-for?perty Address: 1.2 Assessors Map& Pa a umbers
12 L3
1.1a 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 fit) Frontage(it)
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:
Zone: _ Outside Flood Zone?
Public Private ❑ Municipal if yes❑ unicipal On site disposal system ❑
SECTION2-, PROPERTY'OWNERSIIIP'
2.1 Ownert of Record:
IS�rah #r� !ui�sore c3 ern,khq O197D
Name(Print) City,State,ZIP
12 g7e?j 72F-3 EhUkb11r&)/�8 raa
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK''(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': (.1 da (bkha.n Cpr�I%il2aS Gis1a� LOG/7 r
and r-ninor— iniee-ioo -e_loyu-1Yons � hYatrrlh0✓t e ��t
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only_
Labor and Materials
I. Building 1 Building Permit Fee. S Indicate how fee is determined:
❑ Standard Cityff,otvn Application Fee
2. Electrical S ❑Total Pro lectCost',(Item.6)xrnultipher x
3. Plumbing S 2. Other Fees: S .
4. Mechanical (11VAC) S List:
3. Mechanical (Fire $
Sn� ression) Total All Fees: S
Check No. Check ,\mount: Cash Amount. --
6. 'I'otul Project cost: S ❑ Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL)
License Number Expiration Date
Name of CSL holder
List CSL Type(see below)
No. and Street Type Description
U Unrestricted Buildin s up to 35,000 cu. ft.)
R Restricted 1&2 Family Dcvellin
City/Town, State,ZIP M N4asonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
l Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(IIIC)
_ IIIC Registration Number Expiration Date
, IIIC Company Name or It[C Registrant Name
No.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 .......... 0 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 matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic 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
ntamed in his application.is true and accurate to the best of my knowledge and understanding.
P art wner's or,Au horized Agent's Name(Electronic Signature) Z ate
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 not have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the FIIC Program can be found at
wwcv.massoovroca Information on the Construction Supervisor License can be found at wsvw.rnass.eu ' L
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) _(including garage, finished basement/attics, (leeks or porch)
Gross living area(sq. ft.) Habitable room COMA
Number of fireplaces_ Number of bedrooms _
Number of bathrooms Number of half/baths
Type of heating .system -- Number of decks/porches
J'ypeofeoolingsysient_ —� --__-- Enclosed —Open- _
3. "Focal Project Square Footage" may be substituted for"Total Project Cost"