14 PINGREE ST - BUILDING INSPECTION (2) 'fhe Commonwealth of Massachusetts
I}l Board of Building Regulations and Standards CITY OF
\� Massachusetts State Building Code, 780 CNIR SALEbI
R Revised.4lur 2011
Building Permit Application' truct, Repair, Renovate Or Demolish a
One- r Ttvo- ily Dwelling
This Se or Official Use Only
Building Permit Number: Date.App 'ed: rU Z 13
Building Official(Print Name). Signature, Date
SECTION Ii SITE INFO RINIATION
1.1 Prope Address: 1.2 Assessors blip& Parcel Numbers
tier f-p-e
I.I a IsI a is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
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 Cl Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check ifyes❑
SECTION2: PROPERTY OWNERSHIP'
2 Owner'of R ar G
6ca+t tD $� •.�S cols Lt,.e.. o / �2 0
�1me(Pry City,Slate,ZIP
/be- ��.te.F 2� 78r- 3 Fry -4 Y/ 0�c'� g ca d P Ekr-r t-�
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building X I Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s)WC I Addition ❑
Demolition ❑ Accessory Bldg.Cl I Number of Units I Other ❑ Specify:
Brief Description ot•Proposed \York/-• oZ
i^�•..lL�a_ f. 0!7 (7t cncn ,2 S
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S �,�� O I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S
O o '2 ❑Total Project Cost'(Item 6)x multiplier s
3. Plumbing S OG c.'2 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Su nression) Total All Fees:S
Check No._Check Amount: Cash Amount:_
6. 'rotai Project Cost: S a/r O t)O Cl Paid in Full ❑Outstanding Balance Due:
-7e�ia — 38 c� . ?60
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction So or License(CSL) �, r0 52 j 0 l 3 (� (-"
�k � 0, License Number Expiration Date
Name of CSL holder
List CSL"type(see below)
?J . and S—jjj+++'''ggqet t V� Type',- � Description
tj,/C90 � �p (.�.j. ol( /s„ U Unrestricted(Buildings u to 35,000 cu. It.)
e !"6V ' /KIU R Restricted 1&2F:unil Dwelling
Cityfrown,State,ZIP M IMisonry
f O�� �'1 r"L� `l 1 RC Roofing Covering
� r�l WS Window and Siding
[ SF Solid Fuel Burning Appliances
S.
huulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I IIC Company Nnnm or HIC Registrant Name
No. ,aid Street Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'CONIPENSATION 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[Auance 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
tq 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 her by attest under the pains and penalties of perjury that all of the information
coat this applicatio y rue and accurate to the best of my knowledge and understanding.
Print will cd Agent's Name(Electronic Signature) Date
NOTES:
I. An veer who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
t 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 can be found at
www.m:iss."'ov'oca Information on the Construction Supervisor License can be found at www.mas.�_ov'd�s
3. When substantial work is planned,provide the information below:
Total floor area(sq. ftJ (including garage, finished basement/attics,decks or porch)
Gross living area(sq. fl.) 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 ofcooling system Enclosed Open
3. "fatal Project Square Footage"may be substituted for"ToCd Project Cost"
Massachusetts -Department of Public Safety
t�. and Boardof-Building Regulations standards
isor - . . _. ..
Construction Sup'cry '
C_icense'. CS-0321: 'a
MICHpEL E ROS�N
23 LEBLANC Dz o.19a
WEST PEABOD4 MA' `, ,
Expiration"'
-� 0311712014
Commissioner
r
' CITY OF' SALENI, NLXSSACHUSETTS
d BLiLDL\G DEP.kRT1t&NT
3 130 WASHNGTON STREET, 3i1O FLOOR
`` * TF.L (978) 745-9595
F.ALr(978) 740-9846
KIJtBERLEY DRISCOLL
;LLAYOR THo.%w ST.PmRRs
DIRECTOR OF PUBLIC PROPERTY/BUMO NG COMMISSIONER
Construction Debris Disposal Affidavit
re uired for all dem
olition molition and renov
ation vatlon work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL 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 c
111, S I SOA.
The debris will be transported by:
mac.
(name of hauler)
I'hhe debris will be disposed of in
(name of facility)
(address of facility)
i
signature permit applicant
date
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