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11 RAWLINS STREET ' f The Commonwealth of Massachusetts Board of Building Regulations and Standards ZQ 1 MAR ?0 2 OF Massachusetts State Building Code,780 CMR SA1XM Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling Tliis Sectio►Fou Official Use: SEMO Aurldmg P�rnntt+l�omb�r�'" DBtie ,�.�; ,, \ _But>dit►g Oclalmt N.° _" T ll 'O AVI 1.1 Property Address: 1.2 Assessors Nap&Parcel Numbers (� 11 Rawlins Street 16-0133-0 1.1 a Is this an accepted street?yes X no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: R2 Zoning District Proposed Use Lot Area(sq S) 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 D Private 0 Zone: _ ode Flood Zone? Municipal D On site disposal system D ifog : 2.1 Owner'of Record: Donna Williams Salem, MA 01970 Name(Print) City,State,ZIP 11 Rawlins Street 671-510-1385 dwillia1960@gmail.com No.and Street Telephone Enuu7 Address DF9G'RIPIYON QF.lPROFOSSD'WaRK3(cicctiall fiat a ,..__ .. w New Consbuction D Existing Building® Owner-Occupied ® Repairs(s) D Alterations) M Addition D Demolition D Accessary Bldg.D Numba of Units Other M Specify: Replacement Brief Description of Proposed Worle: Replacement of 1 door 5FC"I�N, ��,$TIMA�� 3RUC ®lTS Estimated Costs: 7 — ashor Item and Materials Otl�i7l►ea1y;, 1.Building $ ." 1' '"Itldm$ autee," 2.Electrical S 3708.00 D Standardity�I'oain Appltcst�on 1?ee: 13 TbW' erect Cost; R x 3.Plumbing $ 2. O(he Fea: S 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Sion) 1 $ Total All Fees:S Check No. Check Amexmt: Cash Amount: 6.Total Prole Coat: S 3708.00 D Paid in Full D Outstanding Balance Due: '(0 1�1A1 L)eo SWHON 5: CONS 'RUCTION 3kRviCL3 . ; 5.1 Construction Superv4or License(CSL) 90125 10-06-18 Jamie Morin Lim Number Expiration Date Name of CSL Holder List CSL Type(see below) U 30 Forbes Road No.and Street �ppe x ,,IxiPtwa : Northborough, MA 01532 U Unrestricted to 35,000 cu.ft R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roo WS window and Si SF Solid Fuel Burning Appliances 508-351-2241 rbabostobpermitting(cD-andersencgM.com I Insulation Telephone Email address D Demolition 5.2 Registered Home ilnrprave hent Contractor(HIC) 170810 12-23-17 Renewal by Andersen HIC Registration Number Expiration Daft HIC Company Name or HIC Registrant Name 30 Forbes Rd rbabostonpermitting@andersencorp.com Nortth�ough, MA 01532 508-351-2241 Email address hbor /fo S ZIP Telco SECTION=6 WORKERS'COMPEN3.±11'ION,�CE AFFIDAVIT(MG.LL �152.�� i) 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..........M No...........O GON 7aOb � © mN �x I,as Owner of the subject property,hereby authorize Jamie Morin to act on my behalf;in all matters relative to work authorized by this building permit application See attached contract 3/28/17 Print Owner's Name(Electronic Signature) Date SECTION 7b OR!NER OR�Tl►�7TH011ttIZED AGENT)DEX� DN 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 the best of my knowledge and MAWStDrg. Jaime Morin 3/28/17 Print Owner's or Authorized AgeM's ectronic Signature) Date z 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(HIQ Program),will Mat have access to the arbitration program or guaranty fimd under M.G.L.C. 142A.Odw important information on the 1IIC Program can be found at wwwmasa- lnformabon on the Construction Supervisor License can be found at www.mass.gov/dos 2. When substantial work is planned,provide the information below: Total floor area(sq.R.) (including garage,finished basement/attics,decks or porch) Gross living area(sq,fl.) 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"maybe substituted for"Total Project Cost"