13 STATION RD - BUILDING INSPECTION E2s Cr,
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p4SpEC RECEI VED
�s The Commonwealth of Massachusetts ` 'VICES
lZ Board of Building Regulations and Standards 1915 qp CITY OF
N W Massachusetts State Building Code,780 CMR R 1 Revise� j� II
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Fancily Dwelling
J , This Section For Official Use ly
t Budding Permit Number: Date Applied: -
L _ Building Official(Print Name) Signature Date
IV SECTION 1:SITE INFORMATION
!i 1.1 Prope Add ess: 1.2 Assess a p&Parcel Numbers
("30-- '. M psi Le U)5(D
I.I a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zopin�Information: 1:�rOop�erDimensions: �
c
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 Oyvner of Record;
� ot1 C9 C1\PZ\C to SC��D)I`1\
Name(Print) City,State,ZIP
( �.
No.and Street Telephone Email ddress
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other Specify:
Brief Dese iption of Proposed Worlr:
1A
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ l Building Permit,Fee $ "Indicate how fee is determined"
2.Electrical $ ❑Standard City/Town Application Fee -
❑Total Project Costa(Item 6)x multiplier x
3. Plumbing $ 2 Other Fees $ �L
4. Mechanical (HVAC) $ List G
5. Mechanical (Fire $
Suppression) Total All Fees: $ -
��� Check No. -Check Amount: Cash Amount
6. Total Project Cost: $ ❑Paid in Full ❑ Outstanding Balance Due
SECTION 5:'CONSTRUCTION SERVICES
t 5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted l&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email 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
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:OWNER' 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 and accurate to the best of my knowledge and understanding.
Print Owners o Authot2ed A ame(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 arbitration
program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program can be found at
wtivw_mass.gov/oca Information on the Construction Supervisor License can be found at wwNv.mass. og v/dps
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"
1
MORTGAGE INSPECTION PLAN 14-07657
LOCATION: 13 STATION ROAD BOSTON
CITY,STATE: SALEM,MA
APPLICANT: STEPHANIE ZIRIN SURVEY, INC.
CERTIFIED TO: NATIONAL GRAND BANK
SCALE: 1"=20' P.O.BOX 290220
CHARLESTOWN,MA 02129
PREPARED: SEPT. 12,2014 T(617)242-1313;F(617)242-1616
WWW.BOSTONSURVE)gNC.COM
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* POS IBLE ENCROACHMENT
INSTRUME qT SURVEY IS RECOMMENDED
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deck
1.5 sty.
# 13'
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50.00,
STATION ROAD
FLOOD DETERMINATION REFERENCES
According to Fedend Emergency Mmagement Agmcymaps,the
MOT improvements on this property fall in as area designated DEED/CERT: 25386-325
r p p xrty stgnatedm 'tH pF S
ZONE:X PLAN REF: 4823 278
COMMUNITY PANEL No. 50000$3Z 6 N a° as
Z NOTE: To show an accurate scale this plan must be printed GE CaE
EFFECTIVE DATE: _ j on legal sized paper(8.5"x 14") o
LLINS to
Thepennanent structures am approximately located on the ground as shown. Theyeitherconformedmtbesetbackreguirements o, 4
of the local toning ordinances in elTectat the time ofconatruction,or are exempt/tom violation enforcement action under
M.G.L.Title VB,Chapter40A,Section 7,and thatare no mcroachments ofmajor improvements either my across property F` p�P Q.
lines except as shown and noted hereon. ESS1 p
qNa 'Zile
NOTE: This is not a boundary or00e insurance survey. Thr's p/m was prepared in amordsocc m procedural and tw6nicel
stmdards forMoHgage Loan inspmeions es adopted by the Massachusetts Bosh ofRegishabon ofpmfessiond engineers and
Lmd Surveyors,250CMR6.05,mduseformyotberpurposeisprohibited. Thisplmisrmttobeusedformoording, �.
preparingdeeddamphons,orconstrucdon. George C.Collins,PLS
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