B-17-96 BPA INSULATION The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY M
/ Massachusetts State Building Code,780 CMR BALANI
: Revises!:L/ur 20l l
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only t _t�st ! r-rti
-31
Building Permit Number: Date. .p lied: �
Building Official(Print Name). Signature Date
SECTION 1:SITE INFORMATION' Y:
1.1 Property Address: 1.2 Assessors IViap 3c Parcel Numbers r
`�7 (/i:�a l�rfi� J(�7L
I.la Is this an accepted street?yes no Map Number Parcel Number
� y ., tl 7f •'a
1.3 'Zoning Information: 1.4 Property Dlmenslons It,
"Luning District Proposed Use Lot Area(sq 11) 'Frgntage R);
1.3 Building Setbacks(ft)
Front Yard Side Yards Rear Yana
Required Provided Required Provided Required Provided
1.6 Nater 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 es0
SECTION 2: PROPERTY OWNERSHWI
2.l Qvnerl of Recur / S ,eh �„n
Gt ica 4 r✓ J& !
tme(Print) City,State,ZIP
`f 7 INa rrr�r S'� - �7 --417
No.and Strect Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Pterition(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.O Number of Units I I Other Specify:
Brief Description of Proposed Work':
SECTION 4:ESTILNIATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical S ❑Total Project Cos?(item 6)x multiplier x
3.Plumbing S 3. Other Fees: S
4.Mechanical (HVAC) S List:
5.Mechanical (Fire S Total All Fees:S
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S 3 ❑Paid in Full 0 Outstanding Bahince Due:
Z 2 l M
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) S'75-7 7 L Z3 t1k
License Number Expirdt
Name of CSL HolderElC'IC W. Palm List CSL"type(see below) U
Type Description
No.and Street Salem, lViA 01970 U UnEgdcted Duildin u to 35,000 cu.11
R Restricted U2 Family Dwellin
Cityfrown,State,ZIP M Maso
RC Rootin Coverin
WS Window and Sid!rim
SF Solid Fuel Burning Appliances
9^7 b-7q t1 _ 3 jrE ulation
TelephoneEmail address molition
5.2 Registe�ecl Hgms[,mp�ovement Contractor(HIC) �of
ltnfie Ctl ll'IZatIOII,LLC HIC Registration Number Expiration Date
tIIC Company N ow
No.and Street Email address
Ci /Town State ZIP Tel.enhene
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L C.115Z$2SC(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 Is§uance oJAMbuilding permit.
Signed Affidavit Attached? Yes.......... No•••.......•[]
SECTION-7n-.OWNER AUTHORIZATION TO BE COMPLETED.WHEN,'
OWNER'S AGENT OR CONTRACT61tAPPLIE9 FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
C-n C P/11-1 -
tq act on my behalf ' matters relative to work authorized by this building permit application.
Date
Print Owner's Name(Electronic Signature)
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' his application is true and accurate to the best of my knowledge and understanding.
7.
Print owner's or Authonzcd Agents at (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 nut have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at
ww%v.mass.eoti:!oca Information on the Construction Supervisor License can be found at wvvw.nias�s
2. When substantial work is planned,provide the information below:
'rota) tloor 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 dumber of half/baths
Type of heating system Number of decks/porches
type of cooling system Enclosed Open
3. "rota) Project Square Footage"may be substituted for"Total Project Cost"