BPA-17-34 PERMIT APP FOR PORCH TO KIT. The Commonwealth of Massachusetts r € -r
Board of Building Regulations and Standards j tNAL OF
Massachusetts State Building Code,780 CMR SALEM
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Rgvsgtl�Mar 2011
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Building Permit Application To Construct,Repair,Renovate t
One-or Two-Family Dwelling
This Section For Official Use Only
ZK Building Permit Number: Date Applied:
O t/1}/I'Y'
Building Official(Print Name) Signature Date
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SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
/3 M5ADo w SrrrneE7-
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[]
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Print) City,State,ZIP
/3 MEA,boW 67x--AF7— Gk-302- *' inco nea�o i
No.and Street Telephone Email Addr
SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other 01'Specify:
Brief Description of Proposed Work 2: 9/,Vre,2104 DV-1p1#"n,0,V •' a/l1U. S, CF/L I�t`GS
/AO/204,00o icZowES z�,PCM061q4 or SAVIivC i 1200F
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ " � 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees:(-��� Pe
4.Mechanical (HVAC) $ List: �
5.Mechanical (Fire $
Suppression) Total All Fees:$
6.Total Project Cost: $ Check No. Check Amount: Cash Amount:
20�GOa ❑Paid in Full ❑Outstanding Balance Due:
M 1,t UCEp rt'o cq .0 .
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) C S,S4 o 9437 t/7
E-97`C6 4AJ GAC 6 4�s7-,V_ License Number Expiration Date
Name of CSL Holder
n^w��y ���� List CSL Type(see below)
No.and Street Type Description
p� U Unrestricted(Buildings u to 35,000 cu.ft.
114-* aal9Tb- R Restricted 1&2Family Dwellin
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
y SF Solid Fuel Burning Appliances
7d�'-953-/ G[r►/iMllt�c;�i�[/v1�/�✓�iL/Zon, I Insulation
Telephone Email address /(Q D Demolition
5.2 Registered Home Improvement Contractor(HIC)
JlLA114A iMP Ap,ro✓� E D aLi7r�.� 15'96a-9HIC Registration Number xpiration Date
IC Company Name or HIC Registrant Name
Mc crJl/z,d C ST 1.Ln ling i ft+PdrQ/�lo c�fi.P/11zort.
No and Street Email address 34.0
�t1iyN/ ~ 0/90/ -9S9V
City/Itown,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 ..........er No.
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize J!5-SMAAw L. oqdbl� (UM&M/rT��
to act on m behalf,;in^all lmatters relative to work authorized by this building permit application.
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Print Owner's Name(Electronic Signature) ate
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.
//13/26/7
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. 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. ovioca Information on the Construction Supervisor License can be found at www.mass.govidps
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"maybe substituted for"Total Project Cost"