5 HILLSIDE AVENUE BPA 17-223 CEILINGS & BAY WINDOWS The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
W Massachusetts State Building Code,780 CMR SALEM Massachusetts
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: Dat p Iied:
bl� 3) /
Building Official(Print Name) Signature Date
C� SECTION 1:SITE INFORMATION
1 1.1 Property Address:_ ,( 1.2 Assessors Map&Parcel Numbers
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 system ❑
Check if yes El
SECTION 2: PROPERTY OWNERSHIP'
2.1 Arnerl of Record:
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Descri tion of Proposed Work 2:
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L.&o rZ 13 A4 QA_nc>CAJ
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$- Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
heck No. Check Amount: Cash Amount:
6.Total Project Cost: $ �Q�� ❑Paid in Full ❑Outstanding Balance Due
Lite PI v
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL[folder List CSL'fype(see below)
Type Description
No.and Street U Unrestricted(Buildings tip to 35,000 cu. It.
R Restricted 1&2 Family Dwelling
City/town,State,ZIP NI
Masonry
RC Rootin Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
[IIC Company Name or HIC Registrant Name
No.mid Street Email address
Ci /Town StateZffr Tele hone
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 Is§tumce of the building permit.
Signed Affidavit Attached? Yes ..........❑ No...........0
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 hereb tes5undSphe pains and penalties of perjury that all of the information
contained in th' nppl' i s cc o-Em knowledge and understanding.
-J, 14.1 f '
Print Owners or Authorized Agcn ' ame(EI" onic Signature) ate
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 no have access to the arbitration
program or guaranty fund under NI.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.eoy'oca Information on the Construction Supervisor License can be found at%v%�w.nmss.,ov/.Ins
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 fur"Total Project Cost"