19 BERTUCCIO AVE - BPA-11-52 INSULATION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Buildin O
g Code. 780 C'MR. T"edition F EM SAL
Revised JEM
Building Permit Application To Construct. Repair. nosate Or Demolish a 1. -(MAY
One-or Two-Family Dwelli S.
's Section For Oflici se Only
Building Permit Num r: I Date plied:
r !
n Signalufe: `ZD7
'Ujffl-- Nuilding Cummissi 'In for u in f}rta
(� SE 1 :ME INFORMATION
�fJI 1.1 Pro R97 KGr' A rty,Address: 1.2 Assessors Map& Parcel Numbers
Gve,
I.la Is this an accepted street?yes no Map Number Parcel Number
13 Zoning Information: _ 1.4 Property Dimensions:
Zoning{District Proposed Use La Ama(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
From Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40•§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Public❑ Private❑ Check if es❑ Municipal O On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2./ Ownert of Record:
G L1S (9 %3 cn yzc i o
Nome(Print) i Address for Service:
e 9—iY— 7.qy- goosti
Siynmure Telephone
SECTION l: DESCRIPTION OF PROPOSED WORK"(check all that apply)
New Construction O Existing Building O Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition O
Demolition Cl Accessory Bldg.O Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
at:rJa t___fs �-1•fSs�Gsa't'IO
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee:f Indicate how fee is Determined:
2. Electrical S ❑Standard City/Town Application Fee
O Total Project Cost"(11em 6)x multiplier x
1. Plumbing S 2. Other Fen: S
4. Mechanical (11VAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:f
Vb Check No. Check Amount: Cash Amount:
6. Total Protect Cost: S 300r7- '� O Paid in Full ❑Outstanding Balance Due:
44
CO n'r<r4 c7a �
SECTIONS: CONSTRUCTION SERVICES
S,1 Licensed Construction Supervisor(CSL)
License Number lispimlion Date
Name of L'SI.• I lulder List C'SL type vwc below)
f Uescri ion
:%ddress I U I tlnrestrkted(up to 35.000 Cu.Ft.
R Restricted Id]Family Dwellin
Signature I M I Masonry 11.t1 i
RC ResiJentiol Rooling Covering
felephruse WS RaiJential Window and Sidin
SF RaiJentid Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Registered Hon I vement Contractor(HIC)
I IIC Company Name u C Registrant Name Registration Number
Address Expiration Dote
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. ISI. S ISC(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...........O
SECTION 7n: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature orowner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, MAPS 1411EII f A IGrt./44'n o1i ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are We and accurate,to the best of my knowledge and
�behal
.lawr� �w�
Print.
Signature of owner or Aulhorimd Agent Dale
(silowd under the pains and penalties ofperjury)
NOTES:
1. An Owner who obtains a building permit to Jo his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will sUg have access to the arbitration
program or guaranty fund under M.G.L.c. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I 10.116 and 110.115. respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basementiattics,decks or porch)
Gross living area(Sq.Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of hall7baths
Type of healing system Number of decks/porches
Type of cooling system Enclosed Open
). "Total Project Square Footage"maybe substituted for"Tulal Project Cost"