10 PARLEE ST - BUILDING INSPECTION ! The Commonwealth of Massachusetts
1 Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Nu ber: Date Appli
�Z
Building Official(Print Name) S'gnature Date
SECTION 1: SITE IN06RMATI
1.1 Property Address: I 1.2 Assessors M p& Parcel Numbers
44rlee 4 i
L l a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning 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: PROPERTY OWNERSHIP'
2.1 Owner of Record:
2!M1Co.r& Lv,.tniV�on mO DIg70
Name(Print) City,State,
1a Parlae 5k4 q-75- 82$- '"T
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s1V I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other 6 Specify:
Brief Description of Proposed Work':
1 fiat pOf
rvG (,uDC �1 p
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ q a$C15 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2.Electrical $ , w
0 Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ i List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
a Check No. Check Amount: Cash Amount:
6. Total Project Cost: 1 1) q 8g 16 13 Paid in Full 11 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
Mlt�&,el Lt Mr N License umber Expiration Date
Name of CSL Holder
s kG1540 1 List CSL Type(see below)
No.and Street Type Description
leYYt /Yl l} DI Q�� U Unrestricted(Buildings u to 35,000 cu.ft.
J R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Mason
RC CoveringRoofing Window
WS Window andndSiding
SF Solid Fuel Burning Appliances
Q7j- 745- S34 1 Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) I 86 g 1
/3
Lp w L S Nome Cqo,rl4XtX HIC Registration Number Expiration Date
HIC Compan Name,q�HIC Registrant Name
t36 i,fnot I�
No.and Street , mail address
City/Town,State,ZIP Telephone
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 l'St� C z-m
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 7b:OWNEW 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 this application is true
eeVand accurate to the best of my knowledge and understanding. I
}gicYv..A C� bru-- (\tl1 tAh �� Y"O' 13
Print Owner's or Authorized Agent's Name(Electronic 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 arbitrator.
program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be four.: :
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
2. 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"