147 NORTH ST - BUILDING INSPECTION The Common"ealih of Massachusetts
O t Board of Building Regulanons and Standards Lt )IZ
NH NI( H, \1 I 1
Massachusetts State Building Code. 780 CNIR. 7,;' edition I S1
Building Permit Application To Consu uct. Repair. Renu�ate Or Ihnu, ,h a K, ; l hmuu
` fhrr- orT11(14"Imill Doclliay
'this Section For Official Use Only yi
LNuilding Permit Nt thee: _--- Date :applied: _ --
Sicnature: — - — _ -_ —. ---- - - - _ -_ _
Budding conum.aoncr: In.Pcaor of Budding, D,ue
SECTION 1: SITE INFORMATION -
LI Propero kddress: „/ J 1.2 .Yssessors Map & Parcel Numbers
--------Y7- -
1.la Is this an accepted street' yes_ n0 — Map Number .�.._ _ 1';11re1 Numhei
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area Isy lit F7ontage (it)
1.5.Building Setbacks (ft)
Front Yard Side Yards Rear Yard
! Required Provided Reyuaed Provided RequurJ Proudrd
I
1.6 Water Supply: tM.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone"
Public ❑ Private❑ Municipal if yes❑ unicipal ❑ On site dislrrsal ,yam e ❑
SECTION 2: PROPERTY OWNERSHIPt
2.1 Owner'] fWd: /,9 V, r, , / ?
Name i Print) Address for Service:
I Stgnat ur - Telephone
SECTION ESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building Owner-Occupied ❑ Repaus(s) ❑ Alteration(.,) ❑ Addition ❑
`Demolition ❑ I Accessory Bldg. ❑ Number of Units Other ❑ S coy._ _j
r —
Brief Desaiptiun of Proposed or
,
SECTION J: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: - ---- -�
Item Official Use Only
tl.a ior;md Materials) _
I. Building S w` Q 1. Building Permit Fee: S Indicate hose fee a determined: !
❑ tandard City/Town :\pplicauon Fee
�. Electrical $
❑ Total Project Coat' (Item 6) x in, x
3. Plumbing S 2. Other Fees: S—
S
4. �Nfechanical (EIVAC) S I List
i
5. Mechanical iFire 5
T�wd All Fees: S
So re„wn)
3 / Check No Check Amr,unt ___Cash ttloont
b Total Project Cost: S Y , d o 0 Paid to Full 0 Outsrtndine Balance Uue
SECTION 5: CONSTRUCTION SERVICES _
5.1 censed Cu ctructiun S rpery isor ICSL)
( I_i.:nsc \lusher I[y,Ir unI It6c �, i .t
\ants ol CSL- Ilu `-r S 1)
Lul CSI. pe I sec helaw 1
/qy/� � (. lore>uineJ niolo :�.INIU(L I�I.I
R Resumed 1.(e2 Lomb Uwrll111e
il_n:pure %I \ta>onn Onls
R( Re IJJe n l ul Rao illrH I Can erl
ep 6111 \1S j Re.IJCln lal "Md"„ .'nil
t SF Ke,Ide n l Ial So I I .IcI Iful l I I'I \loll I.1;1, 11'(,,11.,1 J. II ,
. D RrsIJCnl Lil Ucnwhwm �
5.2 Registered Ilcme Improvement Contractor(1110 G
Remtramm . Lush r
I11C Cungianv Nan •Or HIC peg r nt Name g _
n d ---
Address
Ex ran„ )n0.•
Srgnaturt telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT IM.G.L. c. 152. § 2506))
Workers Compensation Insurance affidavit must be completed and suhmi tied with this application. Failure to pnn ide
this affidavit will result in the denial of the Issuance of the building permit. -�
Siened Affidavit Attached'? Yes .......— ❑ No .. ..... ❑
SECTION 7a: OWNER AUTHORIZATION ] BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
L __ —.---.—_.—.-- as Owner of the suhjecl property hereby
authorize — --- _-------_to act tat my brhul t. in all mattes
I
re!atice to work authorized by this building permit application.
Sienature or Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
I.
as Owner or Authorized .\gent herehy declare
that the statements and information on the foregoing application are true and accurate, to the best o(my know!eJ ee and
behalf.
Print Name —
Sienature or Owner or Authorized .Agent Dale
I Signed under the pains and penalties of er a
! NOTES:
I. An Owner who(obtains a building p t io do his/her own w,rik, or an owner who hires an unre��iaercd iuntracnlr
(nut registered in the Hume Improvement Contractor (HIC) Program). will not have access to the :uhnralion
program or guaranty fund under M.G.L. c. I4'_A. Other important information tin the HIC Prugr:un and
Construction Supervisor Licensing (CSL)can be found in 780 CMR Regulations I IO.R6 :md I I0.R5, respectively.
' When substantial work is planned, pio%rde the intiormanon below:
Total flours area (Sy. FL (including garage, finished basentenUatncs, decks or poo:h)
I Gross livmg area lSq. Ft.) Habitable room count
Number ct tireplaces Nwnber„t hed mono _---- _
INumber of hethn,oms - _ Number of ha!r!h:uh,
1-cpe of healing system _ -- Number of dick,/ poi,hes _— -- .-_
Iypeofeuohng ,stem -- IinehoseJ _._
' j �Ihtal Project Syuarc Fuutagt' man' be substituted tior 'Tu(al Project ('ost" '
• '" % > CITY OF SALEN4
^. �. PUBLIC PROPRERTY
DEPAR"I' VIENT
1% 1 U1'r • 1A11 V. MA.,
Ill- ')'9 '4;;);'1i V:-').i4,, _
Construction Debris Disposal Affidavit
(required li)r all demolition and renovation work)
In accordance K ith the sixth edition of the State Building Code, 780 C'MR section I 115
Debris, and the provisions of 11GL c 40, S 54;
Building Permit f is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11, S 150A.
The debris will be transported by:
I name of hauler)
The debris will be disposed of in
(name ul facility) -
1❑Jdress ul lacility)
ignaturc of p.•nnit applicant
date