17 BARTON ST - BPA-12-473 INSULATION the Commonwealth of Massachusetts _ _-
�L11 ✓ t. Board of Building Regulations and Standards CITY OF
si h Massachusetts State Building Code, 780 CNIR SALLM
L'd" Ilr riled.16rr_'lI l/
` Building Permit Application To Construct, Repair, Renovate Or Demolish a
Onc-or Tlvu-/•lonill
This Sectio or Official Use t
Building PermitNum r. We It :
Building Official(Print N;une) Sig Uatc
SECTION 1:SITE INFORMATION
L I Pro arty Add ess: 1.2 Assessors Niap& Parcel Numbers
I.la Is this an accepted street?yes no_ I lap Nunmher Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Coning District Pmposcd llxe Lol Area(sq It) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Pruvided Required Provided Required Provided
1.6 Water Supply:IM.G.1.c. 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if esO Municipal O On sitedisposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.t OP'nert of Record:
5 &1,4" c7 '�annG d S/o-CfA
Name(Print) City.State.LIP
7 7 :T20 ltit-) �T S'Azf-of 97Y--J'4 y-Zd-1� r\ro rem
No,and Street Telephone &nail Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction❑ E.sisting Buildin Owner•Occupie Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':_ 1
it C'iI
SECTION a: ESTINIATED CONSTRUCTION COSTS
licit) Estimated Costs:
(Labor and .\laterials) Official Use Only
I. Building g 1. Building Permit Fee: f Indicate how fee is determined:
2. Llectrical- f ❑Standard CityFrown Application Fee
❑Total Project Cost"(Item 6)s multiplier
' _ _ x i. Plumbing g —
_. Other Fees: f
J. \Icilumicul ill\':\CI S List:_ ___
i5. \lechanical (Fire S
Sum,ressionl 'road .\11Fees: 5
t,. Total Project Cost: S 3l0/, Check No. ---Check Anount: _ _—_- C ash Amount:
0 Paid in Full ❑Outstanding Ilalance Due:
SE("PION 5: CONSI'RUCf1ON SERVICES
5.1 Co/n�struction Supervisor License(C'SL) G Z2ejJT .J'"3 I �i
ICJ{• LH-('4�. '� License Nunther Pq/ira inu hue
N;une of C'Sl. llnldcr r
List CSI.1)Pe Isec helowl---__----
3 o c+ /�✓
.I.s Pe Description
No. ow street
� ��I^ ll I Inres(ncled(Iluddin gs a to J5.I11W cu. It.)
AtfcjA MA— d f F74 R Restricted IX2 14111il Dwcllin
l'itci full n,.State.LlP M Masonry
RC Rlwlin,C'uswrin
-.-_. WS Window;mdSiding
[' 7 SF Solid Ivcl Burning Appliances
T-7Y-7-(I-39 I MAI S I Insulation
'I'rlc hone Finail address 1) Demolition
5.2 Registered Home Improvement Contractor(HIC) p /611 7 /3
M A.9s fig � IIIC Registration Numhcr li you un Uute
IIIC C'ontpan) N;ume or IIIC Registrant Name S/4IGIC/
U. and Street Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c. 152.4 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 .......... ❑ No........... ❑
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 r-/".) ctmtl
to t on my beha In all ma e s relative to work authorized by this building permit application.
Eli k
Print Owner's Name(Electronic Signature) Dute
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 true and accurate to the best of my knowledge and understanding.
�1�)FIiKO L _ /z c 'l
Prim Owner's or.\uthorireJ Agent's Nance(l.lacuunic.Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his her own work,or an owner who hires an unregistered contractor
(nut registered in the Hume Improvement Contractor(HIC) Program),will LLPJ 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
\%N"\ m.n, ;o\ ,�k. i Information on the Construction Supervisor License can be found at k1 o oo nlas�-�o\ dp,
2. U'hen substantial work is planned, pros ide the information below:
Total flour area(.sq. R.) _ __--_(including garage, finished bascmentattics,decks or porch)
Gross lis-ing area(sq. 11.) Habitable room count
Nunlbcroffireplaccs _. --- --- - Numberofbcdroonls
Numberofbathrooms _ —._ Numberofh:dfhaths ... . _ . _- . .
1)pe of heating system _ _ _ -. . _ Number of decks, porches
fsPcOfiO01i'16itStem - Fnclosed _.. -. --011e❑ -
I
1, "Fot,l Project Square Footage" nuq be substituted for"l'otal Project Cost'