BPA 17-65 *`Z-1 o
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'the Commonwealth of Massachu
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Board of Building Regulations and Standards SALEM
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i ��� Massachusetts State Building Code, 780 CLVR JAN 2 l A )y6sed,Lkrr 201/
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dtivelling
This Section For Official Use only
Building Permit Number: Date.Ap ted:
31
Building Official(Print Name). Signature: Date
. 53 j0l/t SECTION Is SITE INFORMATION`
1.1 Pro er Address: 1.2 Assessors Map&Parcel Numbers
g.� 1 � m;W '4ve.
1.la Is this an accepted street?yes ✓ no blap Number Parcel Number
1.3 "Zoning Information: 1.4 Property Dimensions:
"Luning District Proposed Use Lot Area(sq 11) Frontage(It)
1.3 Building Setbacks(ft) /U f�-
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Nater Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: l.8 Sewagee��Disposal System:
Private O Zone: _ Outside Flood Zone? Municipal ffOn site disposal system l7
Public Check if yeser
SECTION Z: PROPERTY OWNERSHIP"
2.t Ownerl R odd:
rt
!me(Print)/, / 7 a )1j City,State,zip,
_7-2- D�
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction O Existing Building 0 Owner-Occupied O 1 Repairs(s) Alterations) Addition 0
Demolition Accessory Bldg.❑ Number of Units I Other O Specify:
Brief Description of Proposed Work': OV-7050-11,A3 6 1;�1��U6f3 A"NA '3phDaM
SECTION•l:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OMcial Use Only
Item Labor and Materials)
1. Building 1. Building Permit Fee:S Indicate how fee is determined:
0 Standard Citylrown Application Fee
2.Electrical S d O i3 O Total Project Cost(Item 6)x multiplier x
3.Plumbing S 2. Other Fees: S
-1.,lechanical (HVAC) S List:
5. 1%lechanical (Fire S Total All Fees:3
Suppression)
ZZ Check No. Check;lmount; Cash Amount:
6.Total Project Cost: s J 0!p d p Paid in Full 13 Outstanding Balance Due:
(via% AE:'n ��31
a� ��
. z
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
,F0 —r !opl 0Gt Lt 0 License Number Expiration Date
Name of CSL Holder List CSL Type(see below)
f Y a-m F Type Description
No.md Street
�� lJ l�v S. U Unrestricted(Buildingsu to 35,000 cu. tt.
1-y N N R Restricted 1&2 Family Dwelling
City/town,State,ZIP M lVasonry
RC Roofing Covering
WS Window and Siding
1 SF Solid Fuel Burning Appliances
791 2s��/93 /�p,�l ifLo�lZy� ��Y� Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) /619�41 61,76 1jk
rhp.3-gei f3(.Deo Af'S —S- HIC Registration Number E.pin:tt n Date
IIIc Cum Name or HIC Registnmt Name
Y6y MV0� s.�- yn��, rri,� 3ah 6462FVertzag •Ne%
No.and StreetlO� Yj ZSR�3 Email address
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 Isivance o the building permit.
Signed Affidavit Attached? Yes.......... 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 -
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'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.
� a `4-
Print Owners 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 trot have access to the arbitration
program or guaranty fund under LM.G.L.c. 142A.Other important information on the HIC Program can be found at
%v%vw.mass.eov'oca Information on the Construction Supervisor License can be found at ww%v.mass.,ov'dns
2. When substantial work is planned,provide the information below:
"notal tloor area(sq. ft.) (including garage,finished basementlattics,decks or porch)
Gross living area(sq. tt.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
'fype of heating system Number of decks/porches
'fype ofcouling system Enclosed Open
3. "rutal Project Square Footage"may be,ubstimted for`Total Project Cost"