17 BARTON ST - BPA-13-1025 2ND FL BATH RENO ' > dJ
The Commonwealth of Massachusetts
�. Board Of Building Regulations and Standards CfCY OF
Massachusetts State Building Code, 730 CMR SALEM
Revised Mnr 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Farnily Dsvelling
Tails SectionForbfficial Us@Oni
Building Permit Number:. _ D ' Appliii&
m1dings0(fieial(Print Name)... C .
SECTION I:SITE INFORMATION
LI P; per AAdldtE s � 1.2 Assessors Map&Parcel Numbers
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 tt) Frontage(it)
1.5 Building Setbacks(ft) #
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(b1.0.L c.e §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesCl
SECT[ONZ:; PROP.ERTti'OWNERSHDP' "
2.1 wrier i (Accord: O (�
t,✓ I k�
XName(Ft(nt) I � City,S;at�— —
No,and Street Telephone Email Address
SECTION 3: DESCRIPTION OF,PROPOSED WORIe'6heck all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Descriptioryry of Proposed Fork3-
r7�5 �rtdh� re1,la �
—
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only.,
Labor and Materials
1. Building S I. Building Permit Fee.--8 Intricate have fee is determined:
�. Electric, $ ❑Standard,City(i7owm Application Fee.
- ❑'rotal Projcct Costt.(Item.6)x multiplier x
3. Plumbing S 9- btherFzes: S
1. M chanical (IIV.\C) S List:
i. Mechanical (Fire S .
5n Cession) _ 1'utal All Fees:.S
Check No. Check Auwunt: _C;tsh :lntuuut:
1'ntal I'rnjeet (' tsC $ �� CUD ❑ I'ai l in Pill ❑Outstanding I1alance I)ne: --
SECTION 5: Co:Vs'i-RUCTION SERVICE'S
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Nameot'C_ (fold-r axe below
List CSL'Typ (.' )
TypeMj
Description
No. and Street
U ted BuiWin s u to 3i,W0 cu. tt.
R d 1&2 Ri Dwellin
City/"rovvn,State,ZIP II RC CoverinWS andSidin.
SF el Burning Appliances
1 n1'cle hone Email address D on
5.2 Registered Home Improvement Contractor(ll[C)
MC Registration Number Expiration Date
1 I IC Company Name or MC Registrant Name
No.and Street Email address
City/Town,State, ZIP Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 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 .......... O No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERNIIT
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) Dnte
SECTION 7h: OWNERt OR AUTHORIZED AGENT DECLARATION
By entering my, a ne below, I hereby attest under the pains and penalties of perjury that all of the information
Q j e t.fined in thi ai tr a and accurate to the best of my knowledge and understanding.
Pnnt Owners or Authorized agent's Nanw(Electronic Signature) Date
NOTES:
!. :\n 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 mar have access to the arbitration
program or guaranty tund under MX11. e. 142A. Other important information on the FIIC Program can be found at
wwvv mas9.euv%uca Information on the Construction Supervisor License can be found at vvww.mass.ror<'dLu
2. When substantial work is planned,provide the information below:
Toed Hour area (including garage, finished basemenUattics, docks or parch)
Gro;i living area(;q. R.) _— ILtbitablo room count
Number of tircpl.rccs. _--_----- Number of bedrooms
Vumhar of bathmulns Nnmher of h;tlbbaths _----_—_---
I' pa ofhe:uimg;y;tcw ." ----_-- NumbenlFdcck.,'porihcs
-- -----
fvpeofcoolin" ;yacm _-_-- Hnclosed .,—_. Open
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