60 SALEM ST - BUILDING INSPECTION r It
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The Commonwealth of Massachusetts Z-7 R5
Board of Building Regulations and Standards
j m MUNICIPALITY
Massachusetts State Building Code,780 CMR, 7 edition USE
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised January
One-or Two-Family Dwelling 1, 2008
Tlys- ¢cfl ' iftlO ctnl [lse.0a
Building Permit Number. ate Applied:
Signature,
. Bill idg G'omrlii9sto�er '1taaPect6tAf S 'ly#togr�
_.
3 (31YfINi - N 7.
` n 1_' Prope aty10Addres�: r - ,0 5 f ,��Yl 1.2 Assessors Map-&Parcel Numbers r p
rT
' 1.1 a is w:<�.acce MaNumber Parcel Number rpted street?yes_ no � 2 P r'
t�(1 1.3 Zoning Information: 1A Property Dimensions: rrn
G
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) n
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❑
SECTION2: PRO v U9 NER$111`
2.1 Ownert of Record: - (� ( / 2 J
(/
Name(Print) Xddress for Service:
97 e-. aI"a 7Ala,z
Signature Telephone
SECTION 3 'DESCRIiiT10N OF 1m,#E„ _ RSORK=(ebeek all thaE altlly)
_.
New Construction 0 Existing Building❑ [Number
Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition -❑ Accessory Bld ❑ of Units_ Other ❑ Specify:
Brief Description of Proposed World: �{t
RIA q wins ,w .
,
SECTION 4:E5 FIMAT NSUCTFQN COSTS
Item Estimated Costs: Official Use
Labor and Materials
1.Building $ f�d.o,V l . _! B Ii t:Fee. $ Indicate: of ee is detennuied:-.
2,Electrical $ ❑Ste>l �ikXlTown Application Fee
1.
❑TotttlQ eet Costs(Item 6)x multiplier x
3.Plumbing $ 2. Otl....
r Feea
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $
S ression Total Alt Fees:$
Check No Check Amount: -Calh Am`oant:
6.Total Project Cost: $ 9, "5,A/v", ❑.Paid.inFufl 0 Outstanding Balance I lice•,
s ro cm r
.tic"
4
ox s: corvsT�ucz3eris�i+e�s
5.1 Licensed Construction Supervisor(CSL)
/D 9.2y
0 License Number Expiration Date
Name of CSL-Hyol r List CSL Type(see below)
�ArnAk '
Address "` =c; . -- Description
/V F � U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 FamilyDwelling
Si a ce �. M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
7�/..3&'7_7F$.L SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2A Regi$tere Home lin r v me nt Contractor(HIC)
X0C* - /fpany N me or HIC Registrant Name Registration Number t
7/og�
//Q t1n�F. )QItg/5 - ����(0 .
Address r •
T
-26 , Expiration Date
Signature Telephone
MC'f[0AI6t �( ' A ei �1 fM 1#1 [ as i t1X? 1{I13.G 1 a lba-g], :-
_Y', n
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...........❑
as Owner of the subject propergshereby-< -
. authorize ^. . `'.:' - - " .. - - . to act on my behalf,in gall matters
relative to work authorized by this building permit,application.
Si lure of Owner Date •�
I, 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.
PritAt N e
V- ,ezm� 0
'SignatudS of Owner or Authorized Ag Date
(Signed under the pains and enalties. f r'
-
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 I I O R6 and 11 O.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 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"