6 PARALLEL ST - BUILDING INSPECTION The Commonwealth of Massachusetts FOR
n Board of Building Regulations and Standards MUNICIPALITY
v Y=
Massachusetts State Building Code, 780 CMR,7 4U(jti;lf s ., USE
Building Permit Application To Construct,Repair,Renovate Or Deingftuhia Revised January
11 One-or Two-Family Dwelling 1, 2008
This Sectio r Official Use 0
Building Pertnit Number: APP
Signature:
Building Commissioned Inspector o in Due \
S 1:SITE INFORMATION
1.1 Pro a /�ddrtss: II Assessors.Map BcJParcrl)Nam ers�itl ,;ir. '
1.1 a Is this an accepted street?yes no Map Number .. "' Parcel Number
.` 13 Zoning Information: IA Property Dimensions: -
- -Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft) -
Fmnt 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: IS Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check ifyes❑
SECTION 2: PROPERTY OR'NERSHIP'
21 Onc ertofRecord: �• �� `0.(�C
?tI, 0 1 e /(e/��
Nae(Print Address for Service:
9-78 --? YS-- VY.7
Signatur Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ I Accessory Bldg.❑ Number of Units_ Other ❑ specify-
Brief Description of Proposed Work': -
SECTION 4: ESTIMATED CONSTRUCTION COSTS
t=stimatedosts: Officia►Use Only
Item - aterials1.Building 1-. BuildingPermit Fee: Indicate how fee is determined:
❑Standard City/PovvnApplication Fee
2.Electrical ❑Total Project Cost'(Item 6)x multiplierx3_Plumbing 2. Other Fees: 3 /__
4.Mechanical (HVAC) $ List: _7
5.Mechanical (Fire $ - - Total All Fees:$
-Suppression) Check No. Check Amount: Cash Amount:
6.Total Project Cost: , $ G ❑Paid in Full ❑Outstanding Balance Due: . -
�G 44
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervise r(CSL) - Q� /97') 123111
- _ License Number Erbtration Date
Name of CSL-Holder � p
I�Itfr&A J I List CSL Type(see below)
. Address S31elD MA Qj 970 Type Description
U Unrestricted hip to 35,000 Cu.Ft-)
Signature R Restricted l Family Dwelling
M MiMMv Only
RC Residential Roofing Covering
Telephone - WS .Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation -
D Residential Demolition -
5.2 Registered Home Improvement Contractor(HIC)
HIC Compan Registration Number
61 R efferm AyeCue
Address
Salem MA 01970
Signature /f /7 .. Telephone
SECTION 6: WORKERS,COW&ENSATION INSURANCE AFFIDAVIT(M.G.L.c 152.g 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 MELDING PERMIT
(,) t l L- as Owner of the subject property hereby
authorize" C P,�� a/ ,.t3 to act on my behalf,in all matters
relative to work authorized by this building permit application.
Si nature of O er Date
JJ--^- SECTION 7b: OWNERt OR AUTHORIZED AGENT DECLARATION -
I, au,t-1-7 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� - _
Lam/! �K L
Print Name
Signature of Amer or Autho Date
(Signed under the pains and penalties of perjury) - - -
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 11 QR6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below: - -
Total floors area(Sq.Ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(Sq.Ft.) Habitable room count -
Number offireplaces Number of bedrooms -
Number of bathrooms Number of halfibaths
Type of heating system - Number of decks/porches
Type of cb'oling system Enclosed Open
3. "Total Project Square Footage"may be substituted°for"Total Project Cost"