1 TAFT RD - BUILDING INSPECTION ' The Commonwealth of Massachusetts
Board ol'Building Regulations and Standards CITY
\ Massachusetts State Building Code, 780 CMR, T°edition OF SALEM
'w Revised Jwruuw
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. :rxlY
One-or Twu-Family Dwelling
J�xv This Section For Of icial Use Only
Building Permit umber: Date Applied:
Signature: /3 /p
Building Commissioner/Inspector of Buildings Nave '
SECTION 1:SITE INFORMATION
1.1 Propel Address_ 2 1.2 Assessors Map& Parcel Numbers
I.l a Is thiaccepted street?yes no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Loi Mea(sq 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rev 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:
Zone: Outside Flood Zone?Public O Private❑ — Check if esO Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow r'of Rec rd:
Name(Print) Address for Service:
r
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check mhat apply)
New Construction O Existing Building❑ Owner-Occupied ❑ Repairs(s) Id I Alterations) ❑ Addition O
Demolition ❑ Accessory Bldg.❑ I Number of Units_ Other O Specify:
Brief Description of Proposed Work': �9Cm 4 y e,V.4{ Simi-Lrq AeeAu C--`Tint f
a
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OMclal Use Only
Labor and Materials
I. Building S e W I. Building Permit Fee:S Indicate how tee is determined:
O Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fm: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:f
6. Total Project Cost: S Check No. _Check Amount: Cash Amount:
0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
/J � 5 I.icense Numher I:.apinlion Date
Name ut CSI.• I Iulder .��,,/��� I.ist CSL Type we below)
Oestri ion
.�J U Inrestricted u to 33.000 Cu.Ft.
R Restricted IR2 Famil D%ellinjs
Signature / M M Only
RC Residential RootingCovering
fclepMme WS Residential Window and Siding
SF Residential Solid Fuel Burning A liartce Inslallatiun
D Residential Demolition
5.2 RegVtered Home Improvement Contactor(HIC) 12— / j 7 Z
I OIC Company Name or HIC Regist t Name Registration Num�/e'�r
AJJrc�ss� �� �� ���(,�(iJ/ Expiration Date
Signature J`�/ / Telephone �U
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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...........O
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.
Si ure of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
i.� ,as Owner or Authorized Agent hereby declare
that the statements and information on th foregoing application arc We and accurate,to the best of my knowledge and
behalf. Ilk
Print Name
Signature of Owner or Authorized Agent Date
FlAn
under the sins and penalties ofperjury)
NOTES:
Owner who obtains abuilding 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=have access to the arbitration
gram or guaranty fund under M.G.L.c. 1J2A.Other important information on the HIC Program and
nstruction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I IO.RS,respectively.
en substantial work is planned,provide the information below:
otaoors arca(Sq. Ft.) (including garage, finished basement/anics,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" maybe substituted for"Total Project Cost"