PER APP 10 REPLACE. WINDOWS B17-46 The Commonwealth of Massachusetts "�
�' y Board of Building Regulations and Standartls ~C i I .` £ CITY OF
Massachusetts State Building Code, 780 CMR SALEM
n Ieyised Mar 2011
Building Permit Application To Construct,Repair, RenovaRlbrAnIoRsA '#�
i One- or Two-Family Dwelling
[` This Section For Official Use Only
Building Permit Number: Date A ied:
Ild
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Pr ertydress: 1.2 Assessors Map& Parcel Numbers
-s; i na R."CA 22
L la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 oning Information: �, _ 1.4 Property D' ions:
_ c m&-
Zoning District Proposed Use Lot a(sq ft) Frontpeffo
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Prov Required P ided Required ided
1.6 Water ply: (M.G.L c.40,§54) 1.7 Floo one Information: 1.8:Sew�aisposal System:
Pu Private❑ Zon Outside Flood Zone'? cipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 wner'of Record:
ric_ Mulse- Sct.� IirYl 4 MA U1Q'ZO
Name(Print) City,State,ZIP
S Q1!,G 5,6WS AJA
No.and Street Telephone Email Address
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 ❑ Specify:
Brief Description of Proposed Work 2: _
1'lti7nn 4, rQL
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I. Building 1 or �' 2 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing 2. Other Fees: $
4. Mechanical (HVAC) $ List: _
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 3�6 2 r ❑paid in Full ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 9 7S /C� 91,31 0018
L(/ 0 s Syec -Sears A� License Number Expiration
r
Name of CSL Holder
O List CSL Type(see below)
48?-71 t�OM6-qnn R
No.and Street Q� �+ 7-77
Type Description 7- 0th 2 77 7� U Unrestricted(Buildings up cu.ft.)
r t� R Restricted I&2 Family Dwelling
City/Town, tate, [P M Masonry
� �'Se�GtrS �GjG n RC Roofin Coverin
WS Window and Siding
SGO � SF Solid Fuel Burning Appliances
763104s?, LSV,��831(Sd Ghlai'L/.gah'1 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home lmprovemenContractor(HIC)Sea V-5 42�.^y /
bV l P)111201-7
gears �b VI-G -A en HIC Registration Number Expir tion Date
HIC Com Name or IC istrant arae
07ALl I v 3 OG WO i .earn,
Po.and Street wroo Email address
'753 . 0452
City/Nfwn, 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 ..........x No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize — VBG
to act on my behalf, in all matters relative to work autorize by this building permit application.5l90t/ 5 B
Eric- M
IS
Print Owner's Name(Electronic Si nature) Date
SECTION 7b: OWNERS OR AUTHORIZED AGENT DECLARATION
By entering my name below,1 hereby attest under the pains and penalties of perjury that all of the information
contained in this application is ruean accurateA the best of my knowledge and understanding.
5 ears
Print Owner's or Authorized s ame ectrom , lure) V , Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregbitratiistere tractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have e aron
program or guaranty fund under M.G.L.c. 142A. Other important inform . n the HIC Program can be found at
www.mass.gov/oca Information on the Construction Superviso rise can be found at www.mass.gov/dps
2. When sub 'o
stantial work is planned,provide the infor n below:
Total floor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. ft.) x Habitable room count
Number of fireplaces_ Number of bedrooms
Number of bathrooms Number of half/baths _
Type of heating syst Number of decks/porches
Type of cooli ystem Enclosed Open
3. tal Project Square Footage"may be substituted for"Total Project Cost"