5 WALL ST - BUILDING INSPECTION (2) 91? 16 8
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR 77 ks'eIV2011
Building Permit Application To Construct, Repair,Renovate Or Demolish a
One- or Two-Family Dwelling
'I'lits,Section For Official Use Only
,�Q Building bee,
fDutc Applied'
Building
Official(Print Name) :Signature Date
SECTION 1. SITE INFORMATION
1.1 Proper=s: A 1.2 Assessors Map&Parcel Numbers
1.la Is this an accepted street?yes �no it9aP Number Parcel Munber
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq In Frontage(it)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required F—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 1� Private 0 Zone: Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yesO
SECTION.2 PROPERTY,OWNERSHIP
2.1 Owneri of Record:
qene c,e- a x if en 9x
Name(Prita) city,state,ZIP
Wo-u s-r V1 309' 15L2
No.and Street Telephone Email Address
PROPOSED W SECTION 3:DESCRIPTION OF ORK (cbeck all that apply)
New Construction 0 Existing Owner-Occupied M-T Repairs(s) 0 1 Alteration(s) 01 Addition 0
Demolition 13 Accessory Bldg. 0 Number of Units 1 Other 13 Specify:— A9,q
Brief Description of Proposed Work 2:
SECTION 4- ESTIMATED CONS UCTION COSTS
Estimated Costs:
Item Official Use Only
(Labor and Materials)
1.Building 66 o 00
E Permit Fee: $ Indicatch6w,fee is determined:
J/
'Q Standud.CitY4'qwh Application Fee
b
2.Electrical $ E Prcj6R:Cost'. (Item Itiplier, x
3.Plumbing $ 1 Other 9 Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total All.Fees:
'$
Check No e Check Amount: Cash Amount
6.Total Project Cost:
ITPaici 'in Full . 0 Outstanding Balance Due.
MAt -M C
SECTION 5c CONSTRUCTION:SERVICES,
5.1 Construction Supervisor License(CSL)
1 /boN3N //-// -aOi7
f) 11 r lo 3 R ie I3Z>° License Number Expiration Date
Name of CSL Hold&
List CSL Type(see below)
No..a�it Street S� Type 'Description -.
�,..I Unrestricted(Buildings u to 35;00(tcur ft.),
V W Ct n M3 R Restricted 1&2 FamilyDwelling
mCityffo! t , Ip M Mason _
V'�\R e�A A—fti C,N-F V1 CYrlf 1.. CQM RC WindoRoofinw
Covering Siding
SF Solid Fuel Burning Appliances
-T&18 yL4 ' el y I I Insulation
Telephone Email address D Demolition
5.2;,�Registesed Home Imrprovement:Contractor(HIC) 3�' 90 9 J' ^l ^a
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(0
Workers Compensation Insurance affidavit must be completed'and submitted with this application. Failbre 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 00h),1 I tJ' 8J� I t wZ�
,to act on my behalf,4n all matters relative to work Tuthorized by this building pennitapplication.
A�'��j _ 6 -ail- /
Print Owner's Naffle(Electronic Signature) V Date
SECTION 76:OWNERi 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 knowfedge arrdunderstartding.
/0 � tom, ,t
ltirr�or Authorized Agent's ame(E ctronic 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
www.mass.eov/oca.Information oathe Construetion Supervisor License can be found at wD w.r�rmass. ov/des
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. "TotalLProject Square Footage"maybe substituted'for"Tbtal'Project Cost"
V JJe q.'cJINJl6JttDPc4��fJi G`yFL[14lrzMtrse�l�
_;k-N fTice of Consumer Affairs&Business Regulation License or registration valid for individul use only
OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
J Registration j5gg0g Type: Office of Consumer Affairs and Business Regulation
Expiration 3743/20t8 DBA 10 Park Plaza-Suite 5170
Bbston,'MA-02116-
P.B. REALTY MGMT
i
PHILIP BRIENZE
57 MURRAY ST APT#2ti..„ry '� g
LYNN,MA 01905 Undersecretary Not vafiid—witthoourt si naturev
5 E Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-100434
Construction Supervisor f `•
PHILIP M BRIENZE -
67MURRAYSTREET.`APT,#2
LYNN MA 01905
r-j,.nn l.l\.._. Expiration:
Commissioner 1111112017
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