2 NIMITZ - BUILDING INSPECTION w,Warp 4h G ,
�. The Commonwealth of Massachusetts RECE,JV CITY OF
Board of Building Regulations and Stand"PECT)ONAC ER (GE$ALEM
Massachusetts State Building Code, 780 CMR
1 fa Revised Mar 2011
Building Permit Application To Construct,Repair,Reno kq*N,*44s,hA 0 5 b
One- or Two-Family Dwellingbo +
This Section For Official Use Only
Building Permit Number: Date Applied:
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9 Building Official(Print Name) Si nature Dat
SECTION 1: SITE INFORMATION
1.1 Pro e Y Addre�sss: — — - 1.2 Assessors Map &Parcel Numbers
/n1 /TZ
L la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information:- 1.4 Property Dimensions:
IZoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private ❑ Zone: _ Outside Flood Zone'? Municipal❑ On site disposal system ❑
Check if yes[]
SECTION 2: P OPERTY OWNERSHIP'
.1 fined f-M n tq
e Pri t) ff City,State,ZIP LJ�
5 � PJi' ✓(( Itil i 4J 11--1��
No.and Street Tl� ._Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIe(check all that apply)
New Construction 13 Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s)OW I Ad ition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
.s
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials) -
1. Building $ D 1., Building Permit Fee:-$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
�7 � Check No. Check Amount: Cash Amount:
6. Total Project Cost: S/�j� I/AV 0 Paid in Full 0 Outstanding Balance Due:
r SECTION 5: CONSTRUCTION SERVICES
5.1 onstr don Supervisor ease(CSL)
lRl License Number Expua[ion Dale
Nay e Ht CSL HlAqolder
s�l ^ List CSL Type(see below)
No.a tree[ (�, n Type Description
//�//�' U Unrestricted(Buildings u to 35,060 cu.ft.
ry o , State,`LIP of !� R Restricted 1&2 FamilyDwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances -
Skmft�" I Insulation
Telc hone Email address D Demolition _
5.2 LRegIA -ister d Home Impro ment Contractor(HIC) • /���� a y !
ram+-, l � pn HIC Registration Number Expiration Date
HI Conrpan Name or HIC Re t ran[Na
NA Stet ' Email address
S5 77�3a1-
C / , State,ZIP Tele hone
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: OWNER 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 71b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in thif application is truA and accurate to the best of my knowledge and understanding.
. ,,
Print(3wner's or Authorized Agent's lectronic Signature) _ Date
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
ww�.rnass.gov/oca Information on,the gonstruction Supervisor License can be found at w��
v. When substantial work is planned,provide the information below:
Total floor 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"