BPA-17-73 SIDING $ ( q 7
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: DateApplied:
0i - "4--1 a
Building Official(Print Name) Signature -b-
Date
SECTION 1:SITE INFORMATION
1.1 Property Address: �, 1.2 Assessors Map&Parcel Numbers
t1.1a Is this an accepted street?yes–LI-1no Map Number Parcel Number 'r'
W f,
1.3 ZoningInformation:
1.4 Property Dimensions: r--,-
cr '
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
-'J
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard I=
Required Provided Required Provided RequiredProvided
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:
14 S O r1 �� V),V1`� A IFl21_let IrIx
Name(Print) l s� City,State,ZIP h
Sf i (:J J/Y l L r� l�'� 1�L) � � �V
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition 11
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:�/' ✓,1
Brief Description of Proposed Work2:
!7* ✓1��r s %kl L L 1. /,l-,- L„'4 A
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materi
1.Building $ 16 e� 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: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
(f�� Check No. Check Amount: Cash Amount:
6.Total Project Cost: $
16 ❑Paid in Full ❑Outstanding Balance Due:
If Y1(k l 1.� Tb C.O N� • '�I �
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) ;(�
l4 Lsur j �)l License RurAber xp' atio Date
Name of CSL Holder
List CSL Type(see below)
No.and Street f Type Description
f ^ t U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
Cityown,Stak,ZW M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registere/d�Home Improvement Contracto HIC) �. � �
'y� f HIC Registration Number E pirati n Date
HIC Company Name or HIC egistrant Name
I t /1 /Y_�fY ,Q rJ
No.an Street
�/ � 1 � Email address
Ci /Town,State,ZIP N Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.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 Iss anc f 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
I,as Owner of the subject property,hereby authorize
to 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:OWNERI 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 understandin .
1 , 2-5-du,) rr
J
Print Owner's or Authorized Agent's Mame(ElecTronrc 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 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/dos
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"