0010 NURSERY ST - BPA-12-443 REDO KITCHEN The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code. 730 C'MR SALEM
Building Permit Application "ro Construct, Repair. Rcnovate Or Demolish a
One-or Tlru-Fuwilr Din elling
This Section For =iui Use Only
Building Permit Number: Date Applicd• _
v �I
(3ui Wing Olticiol(Print N;une) Signatu Date
SECTION I:SITE INFORMATION
I.i0 Property dress:
AJ Ad J£lZ 1.2 Assessor M1lap& Parcel Number
S%,
1.1 a Is this an accepted s reef?yes no Map Nt—anher Tercel Munber
1.3 Zoning Information: 1.4 Property Dimensions:
Tuning District Proposed (Ise Lol Area(sq 11) Frontage(11)
1.3 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:( . I.c.40.§sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zune?
Check fifes❑ Municipal ❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownerl of Record:
CI�iZ/ Sr �f*i �1f�-/�TiN �'I?��j /GI/9.
N;une(Print) City.Slate,TIP
/0 4/u/Ls44'y S%.
No.and Street I Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Ovvner•Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ I Number of Units_ I Other ❑ Specify:
Brief Description of ProposedWorV: �X1 r>J r
L✓n-tbritllr, 9-4- /4 Coy L- A P✓U /S//N U1,S
g2o F/N/C 4 BIG/N&
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Itcill Estimated Costs:
(Labor and Malerials) Official Use Only
I. Building S I. Building Permit Fee:S htdicate how fee is determined:
'. Electrical 5 ❑Standard CityTown Application Fee
❑Total Project Cost(Item 6)x multiplier —_ x
i. Plumbing S 2. Other Fees: S
4. .\lechanical
?. .\leehunieal (Fire ----- ------- --
, .tie p uessiunl S Total :\II Fees:
Cash:\mourn:1, Total Project Cost: 4 � 3 (leg Check No,' --Check Amount:
- --._.--
/ ❑Paid in Full ❑Outstanding Balance Due:
a
i� y fry
' r
SECTION 5: CONSI'RUCTION SERVICES
5.1 Construction Sullen isor License(C'SL) QEi� p S
�h- / .__-_ J7 �/�r �- p Liansc Numhar Pcpiralion U;u¢
Nmnc Of(SI. l lolder �.r Q .—_.___.._..___
List CSI,1)Pe(see heluwl
__3 ~ -L— T.------- I\ Description
No. and Street
O ll t inrcslneteJ(OuilJin-s ti to i5,11110 aa. IL)
Restricted IR2 Fanail Dascllin'
City/faauh,Slate.LIP M Alasun
RC Rtwlin C'uvcrin
_ INS Window and Siding "
if.3-52 p16 0 ""�
/�(IIOAJSj�l UGTi o/J ,SF .Solid Fuel Burninit Appliances
VC fr"N /Lt f I Insulation
1'cic hone [:mail address U Demolition
5.2 Registere1 Home Improvement Contractor(HIC) /e") 7�`�
/ •r�9 COA/S % , �A/ `!'0 IIIC Registration Man —flS.ep—vulit—m Date
IIIC'C'unapuny unc of IIIC' Itegi�lrant Nunhc
No add "0 Q V��1AAA y Sj2 �N a0 Email address
f le
Citvrrown,State,ZIP rule phone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. I52. ! 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 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 Uuner's Name(Electronic Signature) Date
SECTION 7b: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
con i e in t i{a li ation ' true and accurate to the best of my knowledge and understanding.
- Y
Prim Ue ncr's or:\uthurircJ,\gci 's Numc lflccuunic Sign;uurel Date
NOTES:
I. An Owner who obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor
(nut registered in the Hume Improvement Contractor(HIC) Program),will rur have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be round at
n�.n. :;o\ Information on the Construction Supervisor License can be found at -.o% lil.
\Tlien substantial\York is planned, pro\ide the information below:
Total flour area(sq. ft.)_ ____._I including garage, rinished bascment'attics,decks or porch!
Gross living area(sy. 11.) ---- Habitable room count -
\umbcrof fireplaces, __. - .-- \umberofbednxnns
V unaher ol'hathmuaas ,_ _ \umber of h;df paths _ _ _
I)pcofhcatings)stcm .. ._ . _. .._ \umhcnN'decks, porches. . -
i
I")Ile of cooling i)dent _ 1'110oscJ Open
). "total Project Square Footage'ma) he substituted for"1\nal Project Oust"