84 WASHINGTON SQ EAST - BUILDING INSPECTION The Commonwealth of Massachusetts
° Board of Building Regulations and Standards CITY
Massachusetts State Building Code,780 CMR, 7s'edition OF SALEM
Revised January
' Building Permit Application To Construct, Repair, ovate Or Demolish a 1, 2008
1�AJ One-or Two Family Dwel ng
This Sachon For Offic' "Use my
Building Permit Number: Liate Applie
Signature: �y .
Building Commissioner/Inspector, ildmg's, ;- '
ACTION.li$ITE FORMATION,
1.1 Propperty Address 1.2 Assessors Map&Parcel Numbers
1.1a 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 fill Frontage(ft)
1.5 Building Setbacks(it)
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?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION-2: PROPERTY OWN RSHIPi�
2.1 OXvner of Reco d:
P c� . �it�t ' �&Z/ '54 t6
Nam (Pr' a Address for Service:
i na _ 7
s O�
g Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Altcration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units - Other ❑ Specify:
Brief Description of Proposed Work':
/l cat/
SECTION 4: ESTIMATED CONSTRUCTION.COSTS
Item Estimated Costs: Official Use Only
Labor and Materials -y
1.Building $ 1. Building PerdritFee: $ Indicate bow fee is determined:
2.Electrical $ ❑Staridard"City/Town Application Fee
❑Totallzroleot Cos y£ (Item 6)x_multiplier x
3.Plumbing $ 2 Other'Fees $ '
4.Mechanical (HVAC) $ Lrst .t
5.Mechanical (Fire
Suppression) $ 'Total'All Fees`$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $
LT 4 �Q60 ❑,paid in Full ❑Outstanding Balance Due:
-SECTIONS _CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
M ( a lf L to(c-- License Number/ Expiration Date
Name of CSL-Holder List CSL Type(see below) V
P 0 t—� �T '_ , � .:Description
-
Address � .
J .p�� G y U Unrestricted u to 35,000 Cu.Ft.
A �Gr.0 -� R Restricted 1R.2 FamilyDwelling
Signature M Masonry Only
1:2!i 7 L � RC Residential Roofmg Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
- - D Residential Demolition
5.2 Re$ister�H a Iyltprovement Contra for CHIC) .
HIC Co�ppan Name r C Reg t e 0� Registration Number
J
Address
Expiration Date
Signature�.u• / 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 1..........❑
SECTION Oa: OWNER AUTHORIZATION,TO BE COMPLETED.W HE,N
OWNERISS�AGE/NT,OR CONT-RACTOOR-AAPPLIE/S_FOR BUJIILL NG=PERMIT •' ..
I, ! 6 b t0_ Cam" r:%/-�v-y Ll c%�/C/ as Owner of the subject property hereby
authorize � � 21 -� /�� ' / r s� - to act on my behalf,in all matters
relative to w a orized by this building e it appl• atio .
r-. G
Signa&cofOwner - Date
SECTI610¢: OWNER.'OR AUTHORIZED'AGENTDECL.R"TION
I, M as Owner or Authorized Agent hereby declare
that the statements and information-on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
L l
Print Name
Signature of Owner or Authorized Agent Date
Si ned under the pains and penalties of perjury
NOTES: : . 't
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 halfibaths
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"