19 BERTUCCIO AVE - BPA-15-585 FENCE The Commonwealth of Massachusetts
OF
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Board of Building Regulations and StandardsRECEIVED CITYM Massachusetts State Building Code,78 S
V J 41CTIONAL SER I�9,5sedMa,ar2011
( _ Building Permit Application To Construct,Repair,Renovate Or Demolish a
1 One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: I Date pplied:
\ Bmldmg Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
f 1 , 1.1 Pro er Address 1.2 Assessors Map&Parcel Numbers
h
I.la 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(it)
1.5 Building Setbacks(it)
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?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.11 OyLtwpeelri of
R cor C } {�/�
Name Print � � —" ,, ( � I! t 0I-I LlJ
(Print) City State,ZIP
No. Q�{tI>eero flue, 0"T � drdavr.sic Iozl C.cm
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIe(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other A Specify:
Brief Description of Proposed Work2:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1.Building $ 1.Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
El Total Project Cost'(Item 6)x multiplier x_
3.Plumbing $ I. Other Fees: $
4.Mechanical (HVAC) $ List: i
5.Mechanical (Fire $
Su ression Total All Fees:$
o Check No._Check Amount: Cash Amount:
6.Total Project Cost: $ gQD— ❑Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description _
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Faintly Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Bunting Appliances
I 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
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:OWN:ER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,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.
Print Owner's Name(Electronic Signature) Date
SECTION 76:OWNERr OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
qcAnethis l' o is true and accurate to the best of my knowledge and understanding. CQ l�o zed gent's Name(Electronic Signature) Dale
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
wAvw.mass.>oI v;bca Information on the Construction Supervisor License can be found at www.mass.t,ov/dam
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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"
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LANDMARK
ENGINEERING & SURVEYING, INC.
583 CHESTNUT STREET
L YNN, MA 01904
(781) 592-7016