2 WEST CIRCLE BPA 17-91 SOLAR PANELS y
�.
Its, The Commonwealth of Massachusetts
ul" Board of Building Regulations and Standards l rGVy 1;
Massachusetts State Building Code,780 CMR �5 M /�
�— 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 plied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Prope dress: 1.2 Assessors Map&Parcel Numbers
V ' V
l.la 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
Check ifyes❑ P poral system ❑
SECTION 2: PROPERTY OWNERSHIP,
2.1 Owner,of Karen DiRocco Salem MA 01970
Name(Print) City,State,ZIP
2 west Cir 9787895785 Legerm@comcast.net
No.and Street "Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Constructi Existing Building❑ 1 Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ rAddition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Des1ription of Proposed Work2:
JU �7M I
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ i I 1. Building Permit Fee:$ Indicate how fee is determined:
[3 Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ -
4.Mechanical (HVAC) $ List: dj
5.Mechanical (Fire $
Suppression) Total All Fees:$
heck No. Check Amount: Cash Amount:
6.Total Project Cost: $�j 1- 1 0 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) �,.,
�1C.. License Number Expimtion�[la'tee
AN ,%.Prdcr
-� List CSL Type(see below)
No. trees Type Description
U Unrestricted(Buildings u to 35,000 cu.ft.)
Nil R Restricted 1&2 Family Dwelling
City own,State,ZIP M Masonry
RC Roofing ing
WS Window and Siding
SF Solid Fuel Burning Appliances
" , U •QYtI�Q� 1�11j�,�Q�[k(•�Q)( I I Insulation
Telephone Email address D Demolition
5.2 Registered Home Impro ement Contractor(HIC) )7/�i q + 'n
HIC)Reggistration Number Expiration Date
HIC Company N r IC istrant Nam � ` �/"r'( /'!t to n `� ,r,,�1 q,, t�
No.and Street F-U l- •t l&l'�-�� I)y!S EI o l'�t A94
�(`lw try (jl ' �T Email address
Ci /Town,State,ZIP F��1 1 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 .........�� 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 I}� Q b- f-
to
act on my behalf,in all matters relative to work authorized by this building permit application.
Karen DiRocco - 1/30/17
Print Owner's Name(Electronic Signature) 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.
Print O er s or AuthorizelAgent' 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 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.zov/oea Information on the Construction Supervisor License can be found at www.mass.goy/dps
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"