9 WITCHCRAFT RD - BPA WINDOWS (oI cf.1,9 ZI l
The Commonwealth of Massachusetts -
°t9, Board of Building Regulations and StandardsC1Y OF
Massachusetts State Building Code,780 CMR 201b NOV —3 SALEM
¢9(slar2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
D(J This Section For Official Use Only
Building Permit Number: Date Applied:
'9 Building Official(Print Name) " Signature rv,. Da
SECTION 1:SITE INFORMATION
1.1 Property A dd 1.2 Assessors Map&Parcel Numbers
A
l.la 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❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner o Recor /J e
Name(Print) City,State,ZIP
r-1- -« 0
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKz(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Cher ❑ Specify:
Brief Description of Proposed Work':
SECTION 4:ESTIMATED CONSTRUCTION COSTS 1*,
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee: $!a/�Indicate how fee is determined:
$
❑Standard City/Town Application Fee
2.Electrical
❑Total Project Costa(Item 6)x multiplier :' x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression) Total All Fees: $
/ Check No. Check Amount: Cash Amount.
6. Total Project Cost: $ Cl Paid in Full ❑Outstanding Balance Due:
It �� Ntr�tl-ten lt-" sf---IsF- - (oVA-
SECTION5i`CONSTRUCTION SERVICES,
5.1 Llcense(LConstruct(io�n Sune.Mso�r-p(CSL) ,G
Licen�Numb� Exoi_tio Date
Name_ofC L-__ de
Y v� � List C3L Type(see below]
A s T - e - - - --Descri flan.
U Unrestricted to 35,000 Cu.Ft.
Si fare R Restricted 1&2 Famil Dwellia
— a� �� M Mason Onl
Telephone RC Residential RooLn Cov eria
�� WS Residential Window and Siding
SF Residential Solid Fuel Burning fiance Installation
D Residential Demolition
5.2 Re stere . pine-— Went__n—M, NO
or _ ��
e� ` ., a Reei uon,Number
G—
Siena � Expimti___ to
— Teleohoae
Email Address
SECTION 6p WORKERS'COMPENSATION INSURANCE AFFIDAVIT.(M.G.L.c:152.§ 25C(6))
Workers Compensation Insurance affidavit must be co pleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuanc the building permit.
Signed Affidavit Attached? Yes ..........Rr No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE CO._-�VlPLETED IEN
OWNERS AGENE_OI�CONTRA_CTO�t ARPLIESFOR,BUH DING P,ERMIx
authorize ��"' — as Owner of the subject property hereby
---- ------ -- --- - - -- - - ---relative to work authorized b Y this buildin --- -- ---- to act on my behalf,in all matters
g permit application.
i J
Slmaiuie_oCO�vner,
Date
-- SSE�CTIO�N—'7bt OWNERr-0R AUTHORIZED AGENT DECLARATION.
It 01 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.
T'.i_N.,Name
Sienatii�o , ero,A_orizedAeeat / .
(Signed under the pains and penalties of perjury) Date
NOTESe- -
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) g
Gross living area(Sq.Ft.) (including VuuM garage,finished basementlattics,decks or porch)
Number of fireplaces Habitable room count
Number of bathrooms Number of bedrooms
Type of heating system Number of half/baths
Type of cooling system Number of decks/porches
Enclosed Open
3. '"Total Project Square Footage"may be substituted for"Total Project Cosy'