10 MEMORIAL DR - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, T"edition OF SALEM
Revised Jana<gv
Building Permit Application To Construct, Repair, Renovate Or Demolish a /, 7008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: ale A plie :
Signature: �/ /9//D
Building Commissioner/Inspector of uildin A , Date
SECTION ES11JENFORMATION
1.1 Property Address: (� 1.2 Assessors Map& Parcel Numbers
,
I.to Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensious:
Zoning District Proposed Use Lot Area(sq It) Frontage(It)
1.5 Building Setbacks(R)
From 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 Inform atioo: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private[3 Zone:
if ycsCI Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: c\
\IZN
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cbeck all that apply)
New Construction Cl Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': `% C
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (FIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
C' Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S D�h 13 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) i
\Once Numb �[,
License Number li.pima n Uate
Namer�'SL•Iloder \ _ p List CSL Type(see below)_
Descri lion
Address U Unrestricted u to 35,000 Cu.Ft.
Restricted I&2 Family Dwelling
Signature /,, M Mason Onl
RC Residential RoofingCovering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Bumin Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) \5a
\,4 , S Registration Number
IIIC Company Name ur tlIC Registrant rwe l 31�
Address Expiration Dale
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
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 of Owner Date
SECTION 71b:OWNEW OR AUTHORIZED AGENT DECLARATION
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 3
Signature of Ownero Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 VJ 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 780 CMR Regulations 110.116 and I I O.RS,respectively.
2. When substantial work is planned,provide the information below:
Total tloors 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
3. "Total Project Square Footage"may be substituted for"Total Project Cost"