BPA B-17-80 The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
•V,k 'a 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: Date Applied:
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Building Official(Print Name) Signature Date
1
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
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. Owner'of Re�9p r�d: �^
, 0XJAIlA6 ) NZOWA) Sc.ler-�, !"11� ()1570
Name(Print) City,State,ZIP ) /
1�t �ocic�Gl1 ��`� g 5��� 11/S bU�c le f�t(-k,,l►v @(vm"
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of ProposedWork2: r'
U4 tJ S -
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ T v Uid 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical
❑Standard City/Town Application Fee
$ (f�
❑Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ i►t�L� List:
5. Mechanical (Fire $
Suppression) Total All Fees:$
J Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ C�oU ❑Paid in Full ❑Outstanding Balance Due:
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