3 LYNN STREET BPA-17-220 MASTER BATH y� The Commonwealth of Massachusetts .
Board of Building Regulations and Standards CITY
T O
WMassachusetts State Building Code,780 CMR SALEM 2011 MAR 3 � Aev&Ad r 2011
Building Permit Application To Construct,Repair,Renovate Or emolish 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 Property Address: 1.2 Assessors Map&Parcel Numbers
1 3ymy sv 5 AW.
1.1 a Is this an accepted street?yes no Map Number Parcel Number
i1.3 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 IN Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Print) City,Stat6,ZIP
3 /C 1/i+i.lAJ s
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WOR]e(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work : gQpt jL(} R�f/' N-0
eF12Q12Z &AL 2 ✓ /%A' A:, ruG LAII 2C
RE 4s&4l ,Q7 uli Aj&!&d 1",)on t2 A ;t7'�FiV1, ,
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 $ V O LiStandard CiVFown Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ p C) 2. Other Fees: $
4.Mechanical (HVAC) $ U List:
5.Mechanical (Fire $ Total All Fees:$
Suppression) d
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ �( D CJU 13 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) C5- /8
License Number Exp rtiu ate
Name of CSL Holder List CSL'Type(see below)
Tye Description
No.and Street ,A' p U Unrestricted(Bu-ildinuo to 35,000 cu. ft.
R Restricted 1&2 FamilyDwelling
CitylTo%vn,State,ZIP i1Vi Naso
nry
RC Roofin Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Nome Improvement Contractor(HIC)
IIIC Registration Number Expiration Date
"IC Company Nome or HIC Registrant Name
No.and Street Email address
Ci /Town State ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G,L.c.152.¢25C(Q)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Istuance of the building permit.
Signed Affidavit Attached? Yes..........O No....•.•....O
SECTION 7a.OWNER AUTHORIZATION.TO BE COMPLETED.WHEN.-
OWNER'S AGENT OR CONTRAC`fOR APPLIES FOR BUILDING PERMIT'
I,as Owner of the subject property,hereby authorize ^��� W►�?� �A2 -
tg act on my behalf,in all matters relative to work authorized by this building permit application.
Tcm MOR'AN 331 A017
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'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.
ToA-3FAT OvrWsit i- -313/ 017
Print Owner's or Authorized Agent's Name(Electronic Signature) D to
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who(tires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program);will nu 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.uov/oca Information on the Construction Supervisor License can be found at 4vww.mass.1-,ov 4l)s .
2. When substantial work is planned,provide the information below:
"focal 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"