16 PICKMAN ROAD BPA-17-232 REDO K&b The Commonwealth of Massachusetts
Board of Building Regulations and
'lif�iJ"ic`II .�I.rfY
,.! Massachusetts State Building Code, 780 CMR, 7"'edition USE
Building Permit Application To Construct, Repair, Renovate i7!1T TI9lifQa p' vael/Juirrrary
One- or Tiro-Family Dwelling !. 2o08
nn This Section For Official Use Only
Building Permit Number: Date Applied:
Signature:
Building Commissioner/Inspector of EKbildings Date
SECTION 1: SITE INFORMATION
I
1.1 P rope Address: 1.2 :assessors Map & Parcel Numbers ;
�j �CICV`n4vi
L la Is this an accepted street?yes V no Map Number Farrel 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
i
1.6 Water Supply: (M.G.L c.40.-§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
V"" Zone: _ Outside Flood Zone?
Public Private❑ Check if yes❑ Municipal 171—on site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
1 Owner'Qf Record: a
��Hcah i 1L; i �I i C 1c rv.4h 5% QM
Name(Print) Address for Service:
4 O6- 101'1 _
Signature Vim, Vi.` Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Descri tion of Proposed Work':
Zt7 coocn�h \i, ,�w
Ze
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
[tem (Labor and Materials)
$ C`'3 std 1. Building Permit Fee: $ Indicate how fee is determined:
1. Building P13
❑Standard City/Town Application Fee
2. Electrical $ lo(= ob ❑Total Project Cost'(Item 6) x multiplier x
3. Plumbing $ \tb W 2. Other Fees:
4. Mechanical (HVAC) $ List: �.--
5. Mechanical (Fire $ Total All Fees: $
Suppression)
Check No. Check Amount. Cash Amount: �
6. Total Project Cost: $ �j A Ibb ❑Paid in Full ❑Outstanding Balance Due:
00)
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
CS i=A-os5 yeS -1to I (b
Sk,( License Number Expiration Date
Name of`CSL- Holder. M
Z``� ��,v\,Wt, 1,'`� List CSL Type(see below)
Type Description
U Unrestricted(up to 35.000 Cu. Ft.)
R Restricted I&_' Family Dsvelling
Signature M Masonry Only
Cob-III- oc 1 RC Residential Roofing Covering
Telephone WS Residential Window and Sidings
SF Residential Solid Fuel (3urnina :> ilianre Ima.ilLuium
D Residential Demolition
5 Registered. come Improvement Contractor(MIC) �op69 S
s, aeHIC Company Name o HIC Registr• NRegistration Numbe
r
v kLA Til Zoib
Expiratiun
Date
Signature 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 VSG� �� 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.
Signature of Owner ,— —v Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
JIJ ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.R5, respectively.
2. When substantial work is planned,provide the information below:
Total floors 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 hal f/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"
CHET DEMBOWSKI & SON JOB \c
GENERAL
y`
GENERAL CONTRACTING SHEET NO. OF
LICENSED & INSURED
P.O. BOX 412 CALCULATED BY DATE
DANVERS, MA 01923 CHECKED BY DATE
(978) 777-0927
SCALE
y
PRODUCT 204.1(Single Sheets)205-1(Padded)
CHET DEMBOWSKI & SON JOB
GENERAL CONTRACTING SHEET NO. OF
LICENSED & INSURED
P.O. BOX 412 CALCULATED BY DATE
DANVERS, MA 01923 CHECKED BY DATE
(978) 777-0927
SCALE
10
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