6 BERTUCCIO AVE - BPA-14-1458 REMODEL KITCHEN, BR /
LT
s The Commonwealth of Massachusetts RECEIVED CITY OF
Board of Building Regulations and Standa_�r��s,s�RECEIVE' CES
WMassachusetts State Building Code, 78M5 SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renov a pfUlipa U2
One-or Two-Family Dwelling ' lib
This Section For Official Use Only
Building Permit Number: Date�Applied: p
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1. pe Address: 1.2 Assessors Map&Parcel Numbers
13e -I,4 cc 1 p 9��
1.la Is this an accepted street?yes `l no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(It)
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❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes0
SECTION 2: PROPERTY OWNERSHIPt
2: wnert o`u�t
Name(Print) d ,JGIP ¢, el ��j� IName
( City,State,LLIP _
9�a6S 03jZ cJl/OgzC� r1(4yJ�av�
110-arTid Stree[ Te]ephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': �,.� `
6f:' Met j.x RjyAr-ta,,y,
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials) Official Use Only
1. Building $ �p d'DJ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical g ❑Standard City/Town Application Fee
�� ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ "S-p D 2. Other Fees: $
4.Mechanical (HVAC) $ Ltd:
5.Mechanical (Fire
Sup ression) $ Total All Pees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $
12 ❑Paid in Full El Outstanding Balance Due:
1 `u{X ✓� h J� "�tlr °I I O
l
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) ,7 y L
AP77-/J017V C//l}(L{ t% Cn License Number Expiration Date
Name of CSL Holder
A List CSL Type(see below)
No.and Street `- Type Description
kG\_ o U Unrestricted Buildin s u [0 35,000 cu.ft.
v� � 5��� R Restricted 1&2 Famil Dwellin
Ctty/Pown,State,Z
M Ma"
RC Roofin Coverin
WS Window and Sidin
SF Solid Fuel Burning Appliances
I Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Dale
HIC Company Name or HIC Registrant Name
No.and Sneet Email address
Ci /Town,State,ZIP Tele hone
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
1,as Owner of the subject property,hereby authorizerj)y y1 JI �b
to act on my behalf,in all matters relative to work authorized by this uil>�ermit application.
� 41,nP5
Print Owner's Name(Electronic Signature) 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. /t�
N h1,MPs l e5 h�24�cfp! / 7
Pnnt Owner's or Authorized Agent's Name(Electronic Signature) 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 fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
Nti mniass.eov/oca Information on the Construction Supervisor License can be found at wxvw.mass.gov/dns
2. When substantial work is planned,provide the information below:
Total Boor 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"