PER. APP REMODEL 2 UNITS B-17-40 --� l03k
The Commonwealth of Massachusetts
Board of Building Regulations and Standards SALEM
4 Massachusetts State Building Code, 780 CMR Revised,Nur 1011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
( Building Permit Number: DatoAp iedt
j Building Official(Print Name). Signature Date
SECTION 1:SITE INFORNIATION'
L 1 Property Address: 1.2 Assessors Nlap&Parcel Numbers
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Luning District Proposed Use Lot Area(sq ft) frontage(R)
l.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 0 Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system O
Check if esO
SECTION 2: PROPERTY OWNERSHIV
2.1 Owner? Record: } L, /�
�GnN n I vet,, 6ucY�c d 1 ( � I , G k S Sn
NN me(Print) City,State,ZIP
'?� SAe_-kCJs, ':�'sse"c1'e- - s I�cd ao_ ccs
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 Existing Building 0' Owner-Occupied O 1 Repairs(s) Afterntion(s) Nrl Addition O
Demolition 0 Accessory Bldg.0 Number of Units, I Other Specify:
Brief Description of Proposed Work-:
i eA •^cX eo►N- * A C e i'voN
JQ crec% t. C�?VA Cc*.CFP k -*-r %C"f% — \.v,nf%fbLorn,
SECTION 4:ESTINIATED CONSTRUCTION COSTS
Itcm Estimated Costs: Official Use Only
Labor and Materials)
1 Building S ((��r I. Building Permit Fee:$ Indicate how fee is determined:
O Standard City/Town Application Fee
2. Electrical S a(qc)z'C3' O Total Project Costs((tem 6)x multiplier x
3. Plumbing S ICS Cs, 2. Other Fees: S
4."Xleclumical (FIVAC) S OoG List:
t
5.,%fechanical (Fire
Su rcssiun) 'total All Fees:S
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S I gg'lao4 0 Paid in Full 13 Outstandin;Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
,Oh`Z C�w��re License Number Expiration Date
Name of CSL Holder
List CSL'fype(see below)
G I GS N,
No.;md Street Type Description
U Unrestricted(Buildings up to 35,000 cu. tt.
S,gAPw-, t"'\cft O\�tU R Restricted i&2 Family Dwelling
city/rown,State,ZIP ,M IMasonry
RC Roolinst Coverinit
WS Window and Siding
_ ��/� SF Solid Fuel Burning Appliances
9)$'�8"0.g171 �`,X �Pne�1conA/Sl♦;^�rQ I Insulation
Telephone Email address YQ tiCQ D Demolition
5.2 Registered Home Improvement Contractor(NIC) ' k I �5 Go aLoV
`y .,�:_ ()r qfQ I Y\)her-�-�'h GFIIC Registration Number Expiiution Date
IIIC Company Name or 1111C Registrant Name
No.and StreetEmail address
cNev'\ fv\,;, aig7c, Q7�{—SFSO c1�74
Ci /Town State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.15Z.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 IsAuance of the building permit.
Signed Affidavit Attached? Yes .......... No...........O
SECTION 7a:OWNER AUTHORIZATION.TO BE COMPLETED_WHEN,-
OWNER'S
HEN,OWNER'S AGENT OR CONTRACTOR APPLIESFOR BUILDING.PERF UT
I,as Owner of the subject property,hereby authorize _
t9 act on my behalf,in all matter relative to work authorized by this building permit application.
Print Owner's Name(Elecucni ignature) 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 this application is true and accurate to the best of my knowledge and understanding.
17
Print Owner's or Authoriz gent's Name(Electronic Signature) Date
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 nu have access to the arbitration
program or guaranty fund under�1I.G.L.c. I42A.Other important information on the HIC Program can be found at
w%vw.mass.,.-ov'oca Information on the Construction Supervisor License can be found at www.mass.�ov'dns
2. When substantial work is planned,provide the information below:
"total tloor area(sq. ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.tt.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halt/baths
Type of heating system Number of decks/porches
"type of cooling system
Enclosed Open
3. "rota) Project Square Footage"may be substituted I-or"Total Project Cost"