15 BERTUCCIO AVE - BPA-15-542 The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CNIR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This Section For'Official Use Only
Building Permit Number: Date A
V Mz .
uilding Official(Print Name) `Signatti ate -
SECTION 1: SITE INFORNIATIO
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
I � C)c=r�U(CI o As
1.1a 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 ft) Frontage(ft)
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 yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownert of Record: I
cntV-e 7C,nzPrc) M CcAe—FCx--1 C'la vt7y
Name(Print) City,State,ZIP
78 r- 5� 47Yr5s5- I55&
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF:PROPOSED WORK''(check all that apply)
New Construction❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) if I Alteration(s) t� Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': oo �C- c +—
SECTION 4: ESTIMATED CONSTRUCTION COSTS'
Estimated Costs:
Item Official Use Only' .,
Labor and Materials
1. Building S as 1. Building Permit Fee S Indicate how fee is'determined:
�. Electrical S ❑ Standard City%Town Application Fee
1]Total Project Cost,,(Item.6)x multiplier x
3. Plumbing S 2 Other Fees: $
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Su> res-sion) "lbtal:111 Fees: S
Check No. Check Amount: Cash Amount
6. Total Project Cost S —
- .---_--- ---------- - 13Paul in full_ Cl Outstanding Bulnncc Duo--
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) of
5A-c p)-1cn 't _ LiceseNumber Expiration Date
Name of C L Bolder
` - List CSL Type(see below)
Type _ - Description
NoNo. and Street
U Unrestricted Duildin s u2 to 35,000 cu. ft.
R Restricted 1&2 Family Dwellin
City/Town, State, ZIP" I Nlasonr
RC Roofing Covering
1VS Window and Siding
'�77 SF Solid Fuel Burning Appliances
178- 35-7 c �rj I C I Insulation
"rcie hone Email address D Demolition
5.2 Registered Hone Improvement Contractor(HIC)
FIIC Registration Number Expiration Date
FIIC Company Name or IiIC Registrant Name
No. and Street Email address
City/Town, State,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
1, as Owner of the subject property, hereby authorize ) Jl
to act on my behalf, in all matters relative to wo k author' ed b this building permit application.
Print Ownerts Name(Electronic Signature) date
SECTION 7h: 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.
rY)Q nC o.� �& i a a6 L,9-
PrintOwner's or Authorizal Agent's Nary e(Electronic Signature) Date
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 not have access to the arbitration
program or guaranty fund under\LG.L. c. I42A. Other important information on the 1-1IC Program can be found at
www.mass,gov/ocu Information on the Construction Supervisor License can be found at www.nmss.eo�:'dL
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) _(including garage, Ilnished basement/attics, decks or porch)
Gross living area(sq. ft.) _ Habitable room count
Number of fireplaces_- Number of bedrooms _
Nrlmber of bathrooms Number of hal6baths _
Fvpeof heating system ---__--"-_--_- Number ofdecks/ porclies .__- —
type of cooling system Enclosed— ------Open _
). `total PnijectSquurc Fooutge' may be substituted for-Totol Project Cost"