14 VERDON ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
I Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR 7"edition OF SALEM
U Revised January
I Building Permit Application To Construct, Repair, Renovate Or Demolish a I, 2008
One-or Two-Family Dwelling
This'Seohon F,or.Official'Us`e Only
Building Permit Nu er' ."bate Applied::, ' ZKj a
signature: 9I3o/t o
' -Buil&kg Co is ' d Inspector of$uildmgs ` Date';" It
SECTION 1_SITE,INFORMAITION
1.1 Property A ress: 1.2 Assessors Map&Parcel Numbers
Lla 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 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' PROPEREYOWNERSHIP_i:'"
2.1 Ownert Recoy�: ,(
Name(Print- Address for Service:
cnk�
Signature Telephon
SECTION,3:DESCRIPTION OF PROPOSED WORK Z(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTI ATED"CONSTRUCTION COSTS
Estimated Costs:
Item Labor and Materials Official UseOnly
l
1.Bpilding $ 1. Buildmg'P..1m ee: $ Indicate how fee is determined:
2.Electrical $ .❑Standard City/Town Application-Fee
❑TotaF olect Costs Iltern 6)x'multiplier x
3.Plumbing $ 2.,Othei Feesi $
4.Mechanical (HVAC) $ List: "
5.Mechanical (Fire $ ,
Suppression) Total.AllFees. $'
/ L Check No Gheck Amount Cash Amount:
6.Total Project Cost: $ Q� 13 Paid in Full, ❑ Outstanding Balance Due:
SECTION=S CONSTRUCTIO,N SERA ICES
5.1 Licensed Construction Supervisor(CSL)
M (C e L License Number Expiration Date
Name of CSL-Holder _ /l List CSL Type(see below) y
id rU-y U U P 1` (aYA` Tyo, Description
Address ,y' U Unrestricted u to 35,000 Cu.Ft.
"/"`-Y R Restricted 1&2 Family Dwelling
Signature J (M M Masonry Only
13 - - - RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 R,?� tere H e 17provement Contragt r(HIC)
j/Jvt . ILJ y� .�;t-q 44.. L
HIC Cogan Name or C Re t e n Registration Number
Addres�7 '�ZM J-s>fr �i' Y 7 -, 2.�/ el
c
M4w �,l G. � y � 7((( - Expiration Date
Signature / Telephone J
SECTION 6:WORKERS',COM,P.ENSATION 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 AUTHO,RIZATION;TO BE COMPLET W ED HEN:
OWNER'S-AGENT OR CONT.RACTOR'ABPLIES£FOR BUILDING P,ERMTF
I 4 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.
a
Signature of Owner Date
SECTION 7b: OWNER'OR AUTHORIZED AE GNT DECLARATION'
.C�A, 'v J2 d O__tY ,as Owner or Authorized Agent hereby declare
that the statements and informatiorron the foregoing application are true and accurate,to the best of my knowledge and
behalf.
'c, l
Print Name
1/A i
Signature of Owner or Authorized Agent Dat
(Signed under the pains and penalties of du
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 110.R6 and 110.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"maybe substituted for"Total Project Cost'