0035 LAWRENCE STREET - BPA-17-235 BATH lig CK tp5
The Commonwealth of Massachusetts ;„ t ,`R ' > 'OF
�(1 Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR
1�fp1 11 a�pppp _ R s Var2011
Building Permit Application To Construct,Repair,Renovate R D�Yn'dlish a W-
One-or Two-Family Dwelling
[� This Section For Official Use Only
Building Permit Number: Date Applied-)
{N 14!&1 ,V z'_G>J �
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: �\ 1 1.2 Assessors Map&Parcel Numbers
I '.wrens f Kz /
L l a Is this an accepted street?yes Ll 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 Wattef Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage posal System:
Public[(T Private❑ Zone: _ Outside Flood ne?
Check if yes Municipal&On site disposal system ❑
SECTION 2: PROPERTY OWNERSIIIPI
2 Qwner' f I ecoT
Name(Print) City,State,ZIP
3 S/-Cmantt. 0- qA-1'011C-0/�9
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ I Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of UnitsOther ❑ Specify:
Brief Description of Proposed WorkZ: S l ry l a
j// r �/ f, /OIi G n
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ �� d� 1. Building Permit Fee:$ 6 Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
O b, t�0 ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 62 0 Q, , 6 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ � 3Sa ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) x/670 '5"1;7
License Number Expiration Date
Name of CSL[folderr� List CSL'fype(see below) (J
7 `�✓o/� /
Type, Description
No.:uid Street U Unrestricted(Buildings up to 35,000 cu. It.
R Restricted 1&2 Family Dwellin
CitjFfV%vn,State,ZIP ibt —&Masonry
RC Roo ling Covering
WS Window and Sidin
/ SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home I provement Contractor(HIC) /�Sorg Nx $
�ympw'h HIC Registration Number Expiration Date
11 op�p��y N e or H[C Registrant Name MAc4��1J
�� �Oo w;h CO!/�,/r 1� �/
No.qiJ St4eet ✓// Enidil address
9 fl
Ci State ZIP 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§uance of the building permit.
Signed Affidavit Attached? Yes..........❑ No...........El
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 -
tq 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:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,l 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.
Print Owner's or Authorized Agent's Name(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 nu have access to the arbitration
program or guaranty fund under 1M.G.L.c. 142A.Other important information on the HIC Program can be found at
xv%vtiv.mass.eov:'oca Information on the Construction Supervisor License can be found at twww.nia;S.gov/"1711
2. When substantial work is planned,provide the information below:
'notal floor area(sq.ft.) `0 (including garage,finished basement/attics,decks or porch)
Gross living area(sq.tt.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of deck's/porches
"type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
Pauline Afflito
35 Lawrence St.
Salem Ma .
First floor bathroom remodel
CO
V168 I�