1 BERTINI LN - BPA-15-992 REMODEL KITCHEN r
The Commonwealth of Massachusetts CITY`OF$
Com) INSPECTIDIa I S `
Board of Building Regulations and Standards SALEM
/ Massachusetts State Building Code, 730 CMREP
9J; 77�p''S5
Building Permit Application To Construct, Repair, Renovate Or D�tyttTlis a
One-or Two-Family Dwelling
This Section For Official Use Only ..
^ 1 Building Permit Number: Date App '
Building Oilicial(Pont Name) gn
_ , Siature': Dat
SECTION 1:SITE INFOR,VIATION,
1.1 Property Address: 1 Assessors Map&Parcel Numbers x �� I t Q/sB�Dglew�� D19�� L
I.I a Is this an accepted street?yes no M1lap Number P reel umber
1.3 Zoning Information: Ld Pro vert 1 Dimensions: 100 00
Zoning District Proposed Use LaI Area(sq t) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yams Rear Yard
Reyuircd Provided Required Provided Required Provided
1.6 Water Supply:(M1I.G.L c.40,§SJ) 1.7 Flood Zone Information: 1.3 Sewage DDiisposal System:
Zone: _ Outside Flood Zone? Municipal"site disposal system C3Public Private C] Zone:
if esgi
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownerua Record:
i � D m.a �f in l _ 0/q 7, t�
I��hme(Print) City,State,ZIP
koinadt.IM(24 W,6 V01
No.and Street Tele � Email Ad Vg
SECTION 3: DESCRIPTION OF PROPOSEDWORW(check all that apply)
New Constntction❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) ❑ Addition ❑
Demolition qj Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Descriptin of Proposed Work':
X
SECTION 4: ESTIMATED CONSTRUCTION COSTs
Itc t Estimated Costs: Official Use Only
Labor and Materials
I. Building $ I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cosh(item 6)x multiplier x
3. Plumbing S 2�Qther Fees:
Lt. Mechanical (EIVAC) $ List:
5. Mechanical (Fire Total All Fens:S
Su ression)
�, ao Check No._Check Amount: Cash Amount:
X6.T �7otal Project Cost: 3 l�O ❑Paid in Full ❑Outstanding Balance Due:
C) .
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) -
License Number Expiration Date
-
Name of CSL Holder List CSL Type(see below)
Nu. 'ad
Street Type - - Description .
U Unrestricted Buildin s u to 35,000 cu. Il.
R Restricted 1&2 Description
Dwelling
City/Town,Slate,ZIP M Masonry
RC RootingCovering
WS Window and Siding
SF Solid Fuel Ruining 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
Ci /('own State ZIP Telephone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L:e.152.$ 2SC(tW
Workers Compensation insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Isivance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No........... ❑
SECTION 7u;OWNER AUTHORIZATION, BE.COMPLETEDWHEN?
OWN ERIS AGENT OR CONTRACTOILAPPLIES 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.
X b521 5
Print Owner's Name(Electronic Signature) Date
SECTI 7b:OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
cocontained in this applicati`ioon)"iiss'ftrue and accurate to the best of my knowledge and understanding.
pm 6t(
Print Owner's or Authorized A ent's Name( ectronic Signature) /
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 nn have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at
ww.v masss cov'out Information on the Construction Supervisor License can be(round at www.mass._os�'Jns _
t 2. When substantial work is planned,provide the information below:
'rotas floor area(sq. R.) 'a ,(including garage, finished basementlattics,decks or porch)
Gross living area(sq. R.) - Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number or hal f)batlns
Type of heating system Number of decks/porches
'rypeofcoolingsystem Enclosed- Open
3. "Total Project Square Footage"may be.substinund t'or`Toed Project Cost"
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