17 BARTON ST - BPA-14-440 RELOCATE 1ST FL KITCHEN The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
dl / Massachusetts State Building Code,780 CMR SALEM
Revised Mar 201 l
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For Official Use Only
Building Permit Number:- bate.A ted:_
Building Otlicial(Print Name): Signature LX Date
SECTION 1:SITE INFORMATION
1.1 Prirty dre : t ( 1.2 Assessors Map&Parcel Numbers
I.l aIlllIs this an accepted street?yes no Nlap Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zuning District Proposed Use Lot Area(sq R) Frontage(11)
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:
Public❑ Private Cl Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SEMON2: PROPERTY OWNERSHIP'
2.1, kAl- of Record:7
�me(Print) r(� ( (•-\ City,Slate,ZIP
l2 1w41 �. l.�a
No.mid Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Buildin Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) �P Addition ❑
Demolition ❑ Accessory Bldg.AO Number of Units Pther ❑ Specify:
Brief Description of Proposed Work': —
P 4,
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:Labor and Materials) Official Use Only
I. Building S ,� 1. Building Permit Fee:$ Indicate how fee is determined:
Electrical $ ❑Standard City/Town Application Fee2. '
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ _ 2. Other Fees: $
4. Nlechanical (BVAC) $ List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
! c Check No. Check Amount: Cash Amount
6. Total Project Cost: S ( J DD D ❑Paid in Full ❑Outstanding Balance Due:
00tt �, A,,1 4-9
-� t2-V
P-a ���
SECTION 5i: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Dale
Name of CSL Holder
List CSL Type(see below)
No.and Street Type. Description
U Unrestricted(Buildings up to 35,000 cu. 11.)
R Restricted 1&2 Family Dwelling
Citylrown,State,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 250(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 Is§uance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN.
OWNER'S AGENT OR CONTRACTOR APPLIES I FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
t9 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:OWNEW ORAUTHORIZED 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 Owner's or Authorized Agent's Name(Electronic 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
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
am progr or guaranty fund under M.G.L.c. I42A.Other important information on the H[C Program can be found at
www.mass.;oL �Information on the Construction Supervisor License can be found at www.mass.,-mv'dns
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 coma
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"