0010 CARLTON ST - BPA-11-132 The Commonwealth ol'Massachuscus
Board of*Building Regulations and Standards CITY
y )
Massachusetts State Building Code, 780 CMR, 7'edition OF SALEM
Revised Junucffr
Building Permit Application To Construct, Repair, Renovate Or Demolish a I. 2(x1kY
One-or1ri-vZorFamily Dwelling
This scctiWirltr Oficial Use nl
Building Permit Number. to App ' /2
Signature: G/A 11A
Building Commissioner/InspetO w dings tote
SECTION 1: WE INFORMATION
1.1 Property Address: � 1.2 Assessors Map& Parcel Numbers
� n srt
I.la Is this an accepted sireel? esno Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dlmeoslons:
Luning District Proposed Use La Ansa(sq Il) Frontage(It)
1.5 Building Setbacks(0)
Front Yard Side Yards Rear Yard
FPublic
d Provided Required Provided Required Provided
Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Dbposal System:
Private O Zone: _ Outside Flood ZoneT Municipal O On site disposal systemCheck if es0SECTION 2: PROPERTY OWNERSHIP'
r'of Record:
JRm1=S CC)u4N1 l !y /6 C'RRL-TOA2 ST Addrcas for Service:
F Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check aU that apply)
New Construction❑ Existing Building O Owner-Occupied Repairs(s) O 1 Alterations) ❑ Addition O
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': - y—
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Ilem Estimated Costs: O(Ilelal Use Only
Labor and Materials
I. Building S 1. Building Permit Fee: f Indicate how lee is determined:
2. Electrical f ❑Standard Cityfrown Application Fee
❑Total Project Cost'(Item 6)x multiplier x
). Plumbing S 2. Other Fees: f
4. Mechanical (HVAC) f List:
S. Mechanical (Fire S
Su ression) Total All Fen:f
6. Total Project Cost: S /0) 000,00 Check No. Check Amount: Cash Amount:
Cl Paid in Full 0 Outstanding Balance Due:
f '
SECTION S: CONSTRUCTION SERVICES
S.1 Licensed Construction Supervisor(CSL) oadS-(os 2/al
�A I.iccme Number Expiration Date
Name of CII.- I lulder�r List CSL fypelse'e below)
( � f Ikscri ion
Address /1 /1 (! Ilnresuicterl u to)5.000 Cu.Ft.
—r� R Restricted 1&2 FamilyDwelling
Signapture M M Only
RCResidential Routin C'overin
I"deph,ute W'S Residential Window and Siding
SF I Residential Solid Fuel Surninst Appliance Installation
D 1 Residential Demolition
3.2 Registers tome provetnestContractor(HIC) 166 / ( 7
s
I IICI Cuur H�I.Cr-—Rc strait Nume
9, AARegistration Number
( �n,a Y W� le//o �/2
Address - 2 Expiration Date
4 7 B' -2 IES-S5Y
Signature "relephtate
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 132.f 2SC(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 AttachedT Yea ..........O 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 to act on my behalf,in all matters
relative to work authorized by this building permit application.
Si urs of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1 ¢4 t.Q_ ,as Owner or Authorized Agent hereby declare
that the statements and inform lion on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
9�4 t3 L-:'9 P1� F
Print Name Rp�j r3 rL.v Ple r 9/11�to
Signature of Owner or Authorized Agent Data
Si under the eains and penalties of 'u
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 go 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 790 CMR Regulations 1 IO.R6 and I IO.RS, respectively.
3 When substantial work is planned,provide the information below:
Total Moors arca ISq. 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
). ..Total Project Square Footage'may he substituted for"Total Project Cost"