11 BERRYWOOD LN - BPA-2010-865 ROOF The Commonwealth of Massachusetts CITY
Board of Building Regulations and Standards
' � m OF SALF.M
Massachusetts State Building Code, 780 CMR, 7 edition
Revised Junoury
- ' Building Permit Application To Construct, Repair, Renovate Or Demolish a /• =008
One-or Two-Family Dwelling
This Section For Official Use Only
r.
Building Permit Num Date Applied: `7"7" l tJ
Signature:
Building ommissioner/Inspntor of Buildings Date
SECTION I: SITE INFORMATION
1.1 Property Address: L!x 1.2 Assessors Map& Parcel Numbers
I.l a 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 11) Frontage(11)
1.5 Building Setbacks(R)
From 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? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑ p y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Nume(Print) Address for Service:
.q NC
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(cbeck all that apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units I Other .Q-9p,city:
Brief Description of Proposed Work: -
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011lclal Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical S ❑Total Project Cost(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Su ression-
Check No. Check mount: Cash Amount:
6.Total Project Cost: S ��f315 ❑paid in Full ❑Outstanding Balance Due:
SNP/» Jc�O ��''"!r•d�i'l1'7Z
SECTION S: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) l a 01 ya—2 ('/ 02.�/
4u),44a `IA (-MO— License Number lixpirauon Date
Name of CSL. I lolder
/ �(� List C'SL"Type(see below)
.4JJrcss AI� 7 U Unrestricted(up to 35,000 Cu.Ft.
Sign u R Restricted 1&2 Family Dwelling
rr77,p� �7 M Masonry Only
RC Residential Rwfing Coverinit
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
3.2 Regbte ed Home Improgem�Contractor(HIC) q�
�� /71�� ,f•!; / C Registration Number
IiIC Co piny, ame or Ilie Re Nuart Name g
Address
�y�nj �) �� Expiration ate
Signal re Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I..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 ........eCr _ No...........Cl
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
/�I. ®t-(5I'w 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.
Signature of Owner Dale
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
S .Zfi / P'
Signature of n r Aut 'zed Agent Date
Si ned under t e sins and penalties of 'u
NOTES:
1. 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 Mo have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I 10.116 and I IO.RS,respectively.
?. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
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"