13 BERTUCCIO AVE - BPA-15-434 INSULATION The Commonwealth ofMassachusetts
Board of Building Regulations and Standards FOR
Massachusetts State Building Code,780 CMR RE M"eIPALITY
INSPf:CT10,iq l S
Building Permit Application To Construct,Repair,Renovate Or Demolish.a Revrs04�Wl
One-or Two-Family Dwelling
This Section For Official Use Only MAY
Building PermitNumber. Date Appli
BwldingOffieial Oi ntNmme r
11 1 ) Signature Date
._ SECTION 1:SITE INFORMATION
' 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
LlaIs this anacceptedstreet?yes no Map Number ParrelNumber
13 Zoning Information: IA Property Dimensions
ZoniagDistrict Proposed Use LotArea(sq!) Frontage($)
1.5 Building Setbacks(it)
Front Yard Side Yards
. Rear Yard
Required Provided Required Provided Required - Provided
1.6 Water Supply:(M.O.L c.40,§54) 1.7 Itlood rope IpformA(iou: 1r8 Sewage D)sposal System:
Public❑ Private El .Zone: _ Outside Flood Zone? Mania ❑ On site
Checkifyes❑ P� disposal system ❑
SECTION2: PROPERTYOWNERSZIIPt
2.1 Own eri of��5'rd:
NamQQ.A) RQ�tl)ren AWL— —�'� r rt Q Cf7/7
City,State ZlP
I �n v4-i2r la Qa/ Q7 — 1�ly S 34'
No.and t Telephone 8 Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIe(check all that apply)
New Construction❑ Existing Building❑ I Owner-Occupied ❑ 1 Repairs(s) ❑ teration(s) ❑ Addition ❑
Demolition . ❑ Accessory Bldg. NumberofUnits. ! Other LI,Specify:
BriefDescription ofProposed Work':
tAJ
SECTION 4:ESTIMATED CON CTION COSTS
Item Estimated Costs:
abor and Materials Official Use Only
1.Building $ 1. Building PetmitFee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard Cityfrown Application Fee
3.Plumbing $ ❑Tom eject Co'se(Item 6)x multiplier x
2. OdierFees: $
4.Mechanical (HVAC) $ List '
5.Mechanical (Fire
r6T
cession $ Total All Fees $
otal Project Cost $ p Check No.a"j-ChB Amount: Cash Amount
/ A00 ❑Paid in Full ❑Outstanding Balance Due:
SECTIONS; CONSTRUCTION SERVICES
51 Construction SupervisorLicense(CSL) i ."<y79r-7-7 a / 4
LiranseNumber EapirationDate
Name of CSL Holder I3st CSLType(see below)
Eric W.Palm i f
No.and Street 3 Hilton Street i�pe Desraipflon
^ U- Unrestricted to 35 000 ca.R
Salem MA 01970 R Restricted MFamBy Dwelling
City/fown,Stam'ZW M MMMY
RC RODding CoVerbr
WS Wmdow and Sidio
.714 /! SF SolidPoelBmningAppliances:.
✓ Vl I I Iamdation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC) ! 020�/ 3 � lP
Atlantic w eatllcrlLativu, L�..
MCRegrstratron, umber , fthationDate
MccompanyNameorHI venue
���'0ni19nej
No.and Street SelemM Emaitaddress .
' /Town,State,ZIP i Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L r M§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial ofthelssuance e building pemdt
Sigaed.AffidavitAttached? Yes.......... ,( No........_13
SECTION 79:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACI'ORAPPLD3S FORBUILDING PERMMr
i
I,as Owner ofthe subject property,hereby authorize t i/f G
to act on my bebaK in all matters relative to work authorized by this builc&gpmmitappticWaL
Print owner's ITame Wectrunic sigaadne) Date
SECTION 7WOWNERiORAUTHORIZEDAGENTI)EC :&RATION
1 ,
By enteringmy name below,I hereby attest under the pains and penalties of perjury that all ofthe information
contained fiijiis appli n is _ d accurate tothe best of my knowledge and understanding.
Print Owner's orAnthonzed Agent's Name(Electronic Signature) Date
NOTES:
1. AnOwnerviho obtains abuildingpermitta,do hisdier own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(MC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c.142A.Other important information on the HlC Program can be found at
wwwmass.eov/oca Information on the Construction Supervisor License can befoundatmm mass of v/dos "
2. When substantial work is planned,provide the information below:
Total floor area(sq.BL) (including garage,finished basement/attics,decks or porch)
Gross living am(sq.1) Habitable room count
Number of fireplaces Number of bedrooms
-Number-of bathrooms Number-ofhaWbaths
Type of heating system Number of decks/porches-
Type of cooling system i Enclosed Open
3. 'Total Project Square Footage maybe substituted for"Total Project COW.