FULL BATH RENOVATION B-17-31 A,
The Commonwealth of MassachusettsITY
i. '>;
Board of Building Regulations and Standards
I' Massachusetts State Building Code,780 CMR SALEM
Afv,
Building Permit Application To Construct, Repair, Renovate Or Demolish a
ZQ(�
l✓ One-or Avo-Family,Dwelling
�\ This Section For Official Use Only
Building Permit Number: Date Applied:
IAZ I
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Proerty Address: 1.2 Assessors Map&Parcel Numbers
233
I.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? MunicipalOn site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1Owner'of Recorda N �� e�� �I e"A �� 7 0
NA�'�nA✓1 0. a
Name(Print) City,State,ZIP
5 a�,JSCn �}�ee� G/ 7-459-zo(1 9ceb�zo14r( ►icy,
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building[2LN=ub=erof
wner-Occupied ❑ Repairs(s) ❑ Alteration(s) IR Addition ❑
Demolition ® Accessory Bldg. ❑ Units Other ❑ Specify:
Brief Description of Proposed Work 2: 3eMovt i ns k S�r�a 1 c�jl�roo i n Ste �;L
r l/\11 6c. 0� n 0✓i�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1. Building 0 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ��LQ� o� ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing $ Soo 2. Other Fees: $ J/ ) cT
4. Mechanical (HVAC) $ List: �'0�
5. Mechanical (Fire
Suppression) $ Total All Fees:$
c7
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $
�) ��O 0 ❑Paid in Full ❑Outstanding Balance-Due:-
i
i
1
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS-O`70643 7A
„ o1
C&r I Lenjo License Number Extfjirati nDate
Name of CSL Holder List CSL Type(see below) lJL
113 Bo s4° S�r E Q Type Description
No.and Street /�
��M (( I/�� �' �f0 U Unrestricted(Buildings u to 35,000 cu.ft.
MAI / R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
J /"\ I Solid Fuel Burning Appliances
I/ 0
lam' til 2'�`J,,w) �� ,Lush Insulation
Telephone mail address D Demolition
5.2 Re istered Home Improvement Contractlers
r(HIC) /92-%G
644 Z1
Gin l7 rte` 1 HIC Registration Number Expiration Date
HIC C mpany_Name or HIC Registra Name
u ; ��eJ Sir«t �WIdel-(0 /01�A
No.aRg aR Stree Email ddress
q A-210 qG41�
Ci /Town,State,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 ..........1W No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTORAPPLIESFOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize 1�kn)l N GCM
to act on my behalf,in all matters relative to work authorizeo by Ois puilding pe 't application.
e
Print Owner's Name(Electronic Signature) Dafe
SECTION 7b:OWNERS 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 t y know a and derstanding.
►�o� l O�
Print Owner's or Authorized Agent's Name(Electronic Si ature) to
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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dr)s
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"