9 WEST TER - BUILDING INSPECTION (2) n
r,St'ECTIOAl SERVICES
.4:a The Commonwealth of Massachusetts A (V b
Board of Building Regulations and Standards SALEM
/ Massachusetts State Building Code,780 CMR
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Budding Permit Number: Date Applied:
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\Q Building Official(Print Name) 'Signature ( Date
1 SECTION 1: SITE INFORMATION
1.1
Property Address: 1.2 Assessors Ma &Parcel Numbers
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1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zon g/Information: 1.4 Property Dimensions:
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Zoning District Proposed Use Lot Area(sq in 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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system El
SECTION2: PROPERTY OWNERSHIP'
2.1 Owne�Record:
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Name(Print) City,State,ZIP
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No.and S[ [ Ter Telephone Email Address
SECTION.3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building Owner-Occupied � Repairs(s) ❑ Alteration(s) E3" Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': - QXYt e-YL
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SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials
1.Building $ L Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee -
$5D ❑Total.Project Cost'(Item 6)x'.multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ 5-d List.
5.Mechanical (Fire -
Su ression Total All Fees: $
Check No._Check Amount Cash Amount
6.Total Pro'ect Cost: $ (7
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■rail in.Full - ■�utsta g Balance Due:.
F
.'-SECTION5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street -Type I Description
U Unrestricted(Buildings up to 35,000 ca.ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
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.g 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 BUIILDING PERMMIT
1,as Owner of the subject property,hereby authorige
to act on my behalf, in all matters relative to work au orized by this building permit pli tion.
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 ' application is true and accurate to the best of my knowledge and understanding.
P,rin'[ wner's or Authorized Agen ' ame(Electronic Signature) DI e
.NOTES: `
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. ovg_/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
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"