10 WEST CIR - BUILDING INSPECTION \U The Commonwealth of Massachusetts F
O CITY
V
Board of Building Regulations and Standards CITY Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Rep v, enovate Or Demolish a
One-or Tivo-FamilyiDwellin
r This Section For/0fficial Ule Only
Building Permit Number. jD Appli d:
r 7
Building Ofticia (Print N e) i ign r Da e
SECTION 1:SIa'E IN ATION
1.1 Property Address: 7aap
sessors Map& Parcel Numbers
�O In�lS� C(V
1.1 a Is this an accepted street?yes_ no mnber Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use - Lot Area(sq R) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard 'i
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❑ O
Check if yes❑ n site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP`
2+'.1 Owner of Record:
Kai Lan., Sul---, ,N1R 01470
Name(Print) City,State,ZIP
ID (n/r-s Ur bS7 2-05-6k?V
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other Specify:f Lv P(/
Brief Description of Proposed Work': ,r (1 27
e1r s'�` ✓7 a -� loc iirt-cr f � {- -fL� L, c s r/r a-.r t .
S�Sft
SECTION 4: ESTIMATED CONSTRUCTION COSTS'
Item Estimated Costs:
Labor and Materials Official Use Only
1.Building $ 3,750 1..Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ Z� ZSO ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 2 5! "0 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
JG 5y!n R Qctr`n la,,, License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) U
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
(3rt�a,c s✓a�w &Z4 0232°f R Restricted 1&2 FamilyDwelling
City/fo'wn,State,ZIP M Mason
ry
RC ROCifing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
C7 P-2-1 5-2-3 S ft 1 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
/ 1A � 572 3 g is
5�)�aYr `�v HIC Registration Number Expiration Date
HIC Company ame or HIC egistmnt Name
2tf fj. Nlwr F:.. 17 Nrlc�`irn/so,.r��ola✓' e o�
No.and Street
Email address
MA ri-n2 '179f215ZJrf
h .o at ZIP 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...........❑
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 Sv z`vc t�-�x Cov n.
to act on my behalf,in all matters relative to work authorized by t b ilding permit application.
k'o; Lu..-r 61-5 3
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW 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 knowledge and understanding.
N��IG, n;,I � -rJah d�f-3
Print Owner's or Authorized Agent's Name(Electronic 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. og w/nca Information on the Construction Supervisor License can be found at www.mass.gov/dns
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. "Total Project Square Footage"may be substituted for"Total Project Cost"