27 BERTUCCIO AVE - BPA-2010-28 REMODEL KITCHEN The Commonwealth of Massachusetts
� Town of
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7ib edition
Building Dept
assacuses ae g
11111001111
Building Permit Application To Construct, Repair, Renovate Or Demolish a IkgBft*A&
One- or Tiro-Funtili Duelling ANN&
This Section For Official Use Only
Building Permo Nu r: Date Applied: 0
Signature:�96OAP'
riding Commissioner/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Pro erty Address: 1.2 Assessors Map At Parcel Numbers
2'pl 7��z' Cola Ayc 7.,4 0 1 CS '?--
1,1 a Is this an accepted street?yes t/ no Map Number Parcel Number
1.3 Zoning Information: 1.447T Dimensions:
g N -A 0 ��
Zoning Datnct Proposed Use Lot Area(sq R) Frontage(@)
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.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public�A Private❑ Zone: _ Outside Flood one? Municipalv,On site disposal system ❑
Check if es
VSECTION 2: PROPERTY OWNERSHIP'
Owner o r -
��i'>=f� ecord:
Name(Print) Address for Service:
Signature Telephone
SECTION 3. DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) O Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
�\ 9 4
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S z� I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
Z
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 1 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Su ression Total All Fees: S
Check No. _Check Amount: Cash Amount:
6. Total Project Cost: S ZS) � 0 Paid in Full 0 Outstanding Balance Due:
1
I
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supery isor(CSL)
on
" �S • ! y 8.g f^3f J� License Number Expiraton Date
Ngroe y�'SL Helder r List CSL Type(see below)
Address T Description
``�" U Unrestricted(up to 13,000 Cu. Ft.)
v R Restricted 1&2 Family Dwellm
Signature M Masonry Only
RC Rcsidrnnal Roo(in Coverin
Telephone ` ' WS Residrnoal Window and Siding
d 3 �.3 `� � ���> SF Residential Solid Fuel Burning Appliance Installation
�S� D I Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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........... O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, J�.T as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative t WoTk a th ' ed this building permit application.
20ct9
Signature of owner Date
SECTION 7b:OWN ERt OR AUTHORIZED AGENT DECLARATION
/O-4 e,,1 G< rc O.c..'
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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 nn,(have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I0.R6 and 110.115, respectively.
2. When substantial work is planned,provide the information below:
Total floors 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
1. 'Total Project Square Footage' maybe substituted for"Total Project Cost'