2 STATION RD - BUILDING PERMIT APP (002) The Commonwealth of Massachusetts
n 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-Farnily Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
�S
Building Official(Print Narne) Signa ore Date
SECTION 1:SITE INFORMATION
1.1 Property Address: n 1.2 Assessors Map& Parcel Numbers
1.[a Is this an accepted street?yesJe< no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Loning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(fit)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.L,c.,10,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Lone: _ Outside Flood Zone?
Check iryes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSIIIP'
2.1 Owner'of Record:
Namc(Pri it City,State,LIP r
aC d sf,`t.d iIS 978- 7a4- VooF
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Rcpairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed NVork': l�(„i. ` �t_y (<"ny
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials) y
I. Building $ 742 Ie 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x_
3. Plumbing $ 2. Other Fees: $ _
4. Mechanical (IIVAC) $ List:
5. Mechanical (Fire
Sur ression) $ Total All Fees: $--_
Check No. Check Amount_ Cash Amount:
6. Total Project Cost: $ 2/7L , ❑ paid in Full ❑Outstanding Balance Due:
� 0 14 � 'D u �
`ror%n TIC C 'ZS
C r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
r1 -d 4 cos/ L ins �6G
l 4-& Ol'e- ✓• 13�e��t.0 License Number Expiration Date
Name of CSL Bolder
List CS[,-type(see below) L)
No.and Street Tyr Description
lJ I Unrestricted(Buildin s up to 35,000 cu.R.)
"\ Cityl1'own,State,ZIP R Restricted 1&2 FamilyDwelling
S
M I Masonry
.. RC Roofin Coverin
_ INS Window and Sidin
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(IIIC) ir ( j 2S/
)3g,1J�:N g..-F..r ^;Ser - .
P rAc Expiration Date
I IIC Company Name or FIIC Rcgistrmrt Name HIC Registration Number
�ZO rS` G,w_SS ST-
No.and Sir t
kyJ"I A fh4 0 3 ` r Fanail address
City/Town, Stat ,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
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.
Print Owner's Name(Electronic Signature) Dale
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest tinder the pains and penalties of perjury that all of the information -
contained in this application is true and accurate to the best of my knowledge and understanding.
tr. ����09
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. 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 can be found at
www.nmss.eov/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. fl.) (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 ofdecks/porches _
Type of cooling system Enclosed Open _
3. "Total Project Square Footagee"may be substituted for"focal Project Cost"