67 TREMONT ST - BUILDING INSPECTION � 2 4 r2-7b
14� - The Commonwealth of Massachusetts CITY OF
I Board of Building Regulations and Standards�¢ Massachusetts State Building Code, 780 CM SALEM
R Revi.SALE r ZO((
Building Permit Applicatio struct, Repair, Renovate Or Demolish a
One- r Two- mily Dwelling
This-S—ectiod For Official Use Only
Building Permit Number: Date Applies /'0: Z
mo
Building Official(Print Name). Signature' - Date
SECTION 1:SITE INFORtNIATION
1.1 Propertity Adess: f dr s c1 1.2 Assessors Alap 3r Parcel Numbers
� �/2 ho� J�
L I a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provide)
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: PROPERTYOWNERSHIPL"
2.1 Owners of R ord:'' ff
(�a..j v o TC� l� S�•�A r Co 9� A/L O [ 9 O
game(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building 11C Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': �..
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Itc n Estimated Costs: Official Use Only
Labor and ibLuerials
I. Building S O6 p 1. Building Permit Fee:$ Indicate how fee is determined:
�. Electrird $ ❑Standard City/Town Application Fee
V C7" ❑Total Project Cost'(Item 6).e multiplier x
3. Plumbing S v O 2. Other Fees: S
4. ,Mcchanical (IIVAC) S U O. List:
5. Mechanical (Fire S
Suppression) total All Fees: S
Check No._Check Amount: Cash Amount:_
C>. Total Project Cost: S ys v v e7 ❑Paid in Full ❑Outstanding Balance Due:
3 z�
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Su)ervisor License(CSL)
Ao�H` (n License Number 0 Expiration Date
e ot'CSL Hoolderlder
a3 uzciQ (CtK `�rtww ListCSLType(seebelow)A—
No. ;uJ Street 1 Type':' - Description
U Unrestricted(Buildings Up to 35,000 cu. It.)
R Restricted 1&2 Family Dwelling
Cityi own,State,ZIP N1 Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
rC� 1 Insulation
Tale hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Dale
1-IIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State,ZIP role hone
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 Is§uanc a building permit.
Signed Affidavit Attached? Yes ..........V 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
t9 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 ORAUTHORIZED AGENT DECLARATION-
By entering my name below,) hereby attest under the pains and penalties of perjury that all of the information
con mne a plica ' rue and accurate to the best of my knowledge and understanding.
Print Owner's r norized Agent's Name(Electronic Signature) Date
NOTES:
I. A caner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
tot registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty Pond under ibLG.L.c. 142A.Other important information on the HIC Program can be found at
www.moss.eov'oca Information on the Construction Supervisor License can be found at www.ntass.uovAlL
�. When substantial work is planned,provide the information below:
'rural floor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. R.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number orhilf/baths
Type of healing system Number of decks/porches
Type of cooling system Enclosed Open
3. "rotal Project Square Footage"may be substituted for"fotul Project Cost"
i
" Massachusetts -Department of Public Safety
i� ulations and Standards
Board of Building Reg
Construction Supenisor
License CS.032181 }
MICHAEL E ROON
231 EBLANC DR: t-
WEST PEpBOD4 MM Qt
-� 0311712014
Commissioner
r .
CITY OF S.�L E�f, NLXSSACHUSETTS
t . CZL=\,G DEPARTMENT
120 WASHNGTON STREET, Y4 FLOOR
TEL (978) 745-9595
F is(978) 740-9846
KI\tBERL.EY DRISCOLL
%YOR THomAs ST.Ptma
DIRECTOR OF PUBLIC PROPERTY/BUMI)NG CO\MISSIONEQ
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of LNSGL c 40, S 54;
Building Permit A is issued with the condition that the debris resulting from
this work shall be disposed of in a property licensed waste disposal facility as defined by MGL c
t l 1, S 150A.
The debris will be transported by:
ti
y 1/tiw a TVz `/-C-
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature permit applicant
,late