1 BERTINI LN - BPA-14-24 INSULATION _ t
The Cotmnonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Pennit Application To Construct,Repair,Renovate Or Demolish a
One-or Tiro-Family Dwelling
This Section For Official Use Only
1 Building Permit Number: Date Applied: q
1 Building Official(Print Nam St a Date
SECTION 1: STfE INFO I
1.1 Pro erty Address: 1.2 Ass VI arcel Numbers
L la Is this an accepted street?yes ' no Map Number Parcel Number A
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Requied Provided RequdProdded RequiredProvided
ie
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 E3 Private❑ Check if yes0 Municipal❑ On site disposal systnn ❑
SECTION 2: PROPERTY OWNERSI31Pn
2.1 Owners of Record:
Name(Print) City,Stat',ZIP' 1
o.mrd tree[
TelephAie Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Altera[ion(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':!
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item . Estimated Costs: Official Use Only
(Labor and Materials
1.Buildung $ b�•�5, 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing S 2. Other Fees: $
4.Mechanical (HVAC) S List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Aruotmt:
6.Total Project Cost: $ (p 0 a- 0 Paid it Full E3
Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) as"�.1czo VO 3 -\3
License Number Expiration Date
Name of CSL Holder 11
List CSL Type(see below) --ow) V
Type Description
No.and Sheet
Unrestricted(Buildings up to 35.000 cu.ft.
Restricted 1&2 Family Dwelling
City/ own,State M Mas—
RC Roofing Covering
WS Window and Sid nst
SF Solid Fuel Binning Appliances
'\� I Insulation
Telephone �7 Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
61`{� t� r Z.f ('yn HIC Registration Number -Expiration ate
HI Company Name HIC R^egnsti'ant Name
G L'CeY%A ( '1 VCr
No.and Street 1 Email address
AY/To-'v Stat ,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 .......... 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 a,� t- S fh\�� La•lel) fJ(�i!�M l'N/
to act on-my behalf, in all matters relative to work authorized by this Wilding permit application.
19• V� Sign
Print Owner's Name(Electronic Signature) 1'1 e F it 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
contained in this application is true and accurate to the best of my knowledge and understanding.
run.w'oo's or Authorized Agent`s Name(Electronic Signahn'e) Date
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 not have access to the arbitration
program or guaranty fiord tinder M.G.L.c. 142A.Other important atformation on the HIC Program can be found at
www.mass.gov Information on the Construction Supervisor License can be found at w'ww.mass. og,�/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.fl.) (including garage,finished basementlattics.decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/batlms
Type of heating system Nu nber of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage-may be substituted for"Total Project Cost"