11 PICKMAN RD - BUILDING INSPECTION 1 The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY l'
Massachusetts State Building Code, 730 CMR OF
SALEbt
(, Ravised blur 201 l
` 1 Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling.
[his SectionFbrOfficial•Ifsti
Building Permit Number:-
Building Ap
Building Ofrtcial(Print Name) t Data
SECTION I:SITE IN TION
A Pro erty Address: 1.2 Assessors blap& Parcel Numbers
( � t C iC OA*-, IA100-�—
1.1a 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 It) Frontage(it)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.O.L c.40,§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes13
SECTION1. PR0P.ERT16'OWNERSII1l'L '.'
2.1 Owner'of Record:
i ce, � CI, C*.r� . .-
l`t7�
, M✓� o
Name(Print) City,State,ZIP
I( ?i Lke- AA-, 7tr-7y§--l3/y e1e���r (:��w �uF. a t—
No.and Street - - Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED.WORK"'(check all that apply)
New Construction Cl Existing Building❑ Owner-Occupied 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify;
Brief Description of Proposed Work": U1& i't 7 a l S ao T
SECTION 4: ESTlivL4TED CONSTRUCTION COSTS-
Rem Estimated Costs:
Labor and Materials OfRclnl Use Only;..
1. Building 5 ,�— I..Building.Permit Fee:S rndicate how fee is determined:
2. Electrical g ❑Standard._City/fotvn Application Fee
S`�U ❑Total Prcject Cost"(Item.6)x multiplier x
3. Plumbing 06d. 2. Other Fem.-3
I. Mechanical (IIVAQ S - List: -
. Mechanical (Fir» $
in , ircssiun) _ Total All Fees:.5_
Check No. _Check Auwunt: _cash Autounr
n I'ntal Project Cuit: S O Paid in EIIH Cl Outstanding Mliance Ouo:
sEC'rION 5: CONs'l-RUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Ilolder
List CSL Type(see below)
rype Description
No. and Street
U Unrestricted Duildin s u to 33,000 cu. tt.
R Restricted 15t2 F;unil Dwellin
Ciry/Town,State,ZIP �I Mason
RC Rootin Coverin
WS Window and Sidin
SF Solid Fuel Burning Appliances
I Insulation
1'ele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
MC Registration Number Expiration Date
I IIC Company Name or IIIC Registrant Name
No.and Street Email address
Ci /Town State,ZIP role 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
1, 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.
z///3
F13y
nana(Electroni S gnature) Dnte
SECTION 7h: OWNERtOR AUTHORIZED AGENT DECLARATION
entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
ained in this application is true and accurate to the best of my knowledge and understanding.
Print Qwner's or Authurited:\;ent's Mane(Electronic Signature) Date
NOTES:
I. :1n Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program can be found at
www m;us.��ovh7ca Information on the Construction Supervisor License can be round at ww•tv.mas .vuy :'AIL
2. When substantial work is planned,provide the information below:
Toed floor area(ml. It.) _(including garage, finished basement/attics,decks or porch)
tiros; living area(iq. ft.) Habitable room count _
Number of fircpl,tecs_. Number of bedrooms
---- —
Number of bathmonts ---___--- Number of halt'baths
I'cpe of heating ;yitent . .. --- _-- Number of dcck.i/parches
I\pe0(caolim" iyacnt ---.--,_ Enclo.ied ___ Opcn ---_------- ---
4. I'ot d I'r q:et Oyu va I not i e 'in.ry he iuhititnt'-d tau '1„tit I'n,jad l'o<t"
CITY OF S,6Uz6 t, NWS.\cHusETTs
,t1 BI:tLDVG DEP.SRTtE,VT
120 CU.53HL`fGTOV STSiE&T, 31°FLOOR
\ s%^ TEL (978) 145-9595
tUJ10t0E2LSY DRISCOLL Ft.Y(978) 7•W-9344
,bL�YOR 1110SN3 ST PtERM
Dt: wrort OF Pt:uuC PROPERTY/8LaMLYG CONWISSIO,NER
Construction Debris Disposal Aff1davit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Coda, 730 CL%rR section I l LS
Debris, and the provisions of lb1GL c 40, S 54;
Building Permit# 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 NIGL o
I 11, S 150A.
The debris will be tr wsportcd by:
(name ut'hautur)
The debris will be disposed of in :
S.
(nonta of tJcilily)
--_-- ' drC 9a u!tilailil%)
;i�;uamre of Cr p mit applicant
i
CITY OF S.U-F.bI
PUBLIC PROPERTY
DEPAR T,ti(ENT
V f�Si O•{1L,Yy
wrae
t b wU++wrd moor• U,sa<.MAeua4 MM Ot 9"4
nn.rar�s.vsss •v..a r.t.nd�w
HOMEOWNER LICLNSB E.X1.l "j0,V
• Aft" "I
Date
lob L«adori I I �'i c(�,,,� r-i
Home OwnerAddresg II
Home Owner Telephone 7 f 7 y/— 0 03
Present Manias Addrese_(L 1� c,C hn�n rZ L
The current e:emptiao of"Homeowners"wag extended to inohtde owner-occupied
dweUinp o[two Unit#or leas and to allow such homeowners to Capp an individual for
hire who doer not poasear s Uc=4 provided that the owner sets as aupwWnor.
DERNMON OF HOMEOWNER
Persons) *he owns a pared of WW an which hdsbe raidae or iota ds to reWd@6 00
which there it; or is intended to be,a one or two Awdly dweWnf, attached or detached etntttsueg accessory to such use and/or farm structures, A petrsoa who constructs mo
hall
thm one home fo a two year period s rut be considgrud a homeowner. S re
uch
"homeowner"shall submit to the Building OUleial,on s form acceptable to the Building
Permit
Otllciai, that hatshe be responsible for ail such wort performed under the Building
The undersiowd 'hamesownde assumes responsibility far compliance with the State
SuildinS Code and other applieabls bylaws and reluladona,
The undersigned "homeowner"certilles that halshe undentands the City of Silent Building Department minimum inspection procedures and requirements and that helshe
.vill comply with said procedures and requirement&
HOMEOWNERS SIGNATLC�tJ
kPPROVAL OF 9UlLor 4YSPECTOR
See other side for state code