14 WILLIAMS ST - BUILDING INSPECTION (3) 67
I The Commonwealth of Massachusetts
q ql, Board of Building Regulations and Standards CITY
Ih Q Il Massachusetts State Building Code,780 CNK 74 edition Ois SALEM
U}�I Revised January
Building Permit Application To Construct,Repair,Ren ate Or Demolish a 1, 2008
One-or Two-Family Dwelling
/ vudlltngTettttttNutitbe� ISate .p
Signature ua+wl �1!2 fl
` BiilldtagC4mintsatoneillnspectorofB,_
SPIG � Jj1N
1.1 Property Address: 5 1.2 Assessors Map&Parcel Numbers
� 'rim
1.1 a 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❑
CTIpIV^.`=PI2A_ It,< } lVLRS7(iIPt ; . , "
2.1 Owner'of Record: / C
Name(Print) ,/ Address for Service:
Signature Telephone
Sl CT1ON3 .DE& xlPCdl ct51 p£WRK=(c eekallt hatapply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed_Work : _ 5-,L— ,p
SECTION 4: ESTIiY1AI :GONSTRIF"IION COSTS}:
Estimated Costs:
Item Labor and Materials +l3ttiorT 17se OnJ�
1.Building $ Indicate how fee is.determined:
2.Electrical $ �fl Standard Gt13/Town Apphcdtton Fee
C�Tit E PebJeot Co ( e1P b)z ptyltapI ter,; x
3.Plumbing $ � } +$geS, a Q
a .-,.. ...., x
4.Mechanical (HVAC) $ tj'
5.Mechanical (Fire $
Suppression) Totbb? 11Fees $ a
jleCk No �,t heck Amount , Cash Amount:
6.Total Project Cost: $ �� Gpard in Fyll CI Outstanding Balance Due:
J
5.1_Licensed Construction Supervisor(CSL) , -7 1 4�72
M (CIA-if L `' In rc(cam License Number Expiration Date
Name of CSL-Holder List CSL Type(see below) y
's, to K L")00
Address
U -Unrestricted u to 35,000 Cu.Ft.
A/ Q� / R Restricted l&2 Family Dwelling
Signature pf� M Masonry Only - t
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 R ' ter H e I provement Contraor(H
LL..fIC) le
S
HIC Cotypan Name or HIC Re,
e t e Registration Number
I� Address
Gh ` J 7k 74A rq'35 Expiration Date
Signature �a• / Telephone
SECT3ON 6 WRKEIISrOMPISNS}�TQI1($U )YG}F AFFIIIAVIT(M G.I c 152.§-25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTI9N:fa OWNER AIITHORi$ATiQN 7) ,C t r €. , 41
I) F k
OWP}ER'S.AGENTf?RCNT21GTORi1PIjIS3I"ORBIIIi IN, J'ERI41[T ,
I G{vj OAet m 6-h t!�Ziv �u SS Owner of the subject property hereby
authorize �t r s to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date /
SEGIIUN?b,UR �,w Q >�3'y1G �DEC -,A,
Q
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
Print Name
Signature of Owner or Authorized t Date
(Signed.under the pains andggaltic;ofI;JMW
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 importantinformation on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 I O.R6 and 110.115,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 Cosy'