SM ADDITION W/MASTER BATH TBA-17-234 The Commonwealth of Massachusetts; h i V
Board of Building Regulations ant1SfiWifiN A . * i .. ,1. CITY OF
i Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,KhMeOd D&oW>
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date A plied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
10 d�44Vfxbrd 5hze'it
1.1 a Is this an accepted street?yes no Map Number Parcel Number
13 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❑
SECTION 2: PROPERTY OWNERSHIP'
2 Owner'of Record: ��
1��1,6111Gel � ( Jr/ Lie lle✓ /", fel/) C/'�l
Name(Print) City,State,ZIP
J0 9" Y�in d S jy'ee
No.and Street V Telephone Email Address
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 Description of Proposed Work': ' L? Gil Wu ta'T 4-
0 � /or ,i d bar
a
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ / // ( �'Zi L7J 1. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $ L/)�� ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2 )"D )J 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ �� .�j ❑Paid in Full ❑Outstanding Balance Due:
AVE P L.l�N S
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) `
All License Number Expiration Date
Name of CSL Holder
'f I CJ List CSL Type(see below)
&�(,kd
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town, te,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
I i SF Solid Fuel Burning Appliances
'��I"c���'�2��) N1CCL'YNl tl _l� �" �t2 �`f{��U•Ci�jJ I Insulation
Telephone Email address D Demolition
5.2 (R�,egistered Home Improvement C tractor(HIC)
ML`ti a( S � 0 k� J 11A JY" HTC Registration Number Expiration Date
HIC Company Name or HTC Registrant N e
G s (W 7
and Street
J , I �N )Ll J Email address
Ci /T n,State,ZIP
Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AF AVIT(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,as Owner of the subject property,hereby authorize rV a P lm I(L(-J-1/
to act on my behalf,in a afters relative to work authorized by this building permit application.
Print Oer' me(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 the best of my knowledge and understanding.
0 �I I� cd6mra, ,.�7 � -3 -zl7
Print Owner's or Authorized Agent's Name(Ele .onic ature) Date
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 can be found at
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass. og v/dps
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"maybe substituted for"Total Project Cost"
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1.5 STORY
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30.89
HARTFORD STREET
1994(c)9osfon Survev Software
SCALE. 1 inch =30 feet
CERTIFIED TO: AMERICAN TRUST MORTGAGE INC
PREPARED: 02-17-2005
The permanent structures are approximately located on the According to Federal Emergency Management Agency
ground as shown.They either conformed to the setback ��p1ZH OF 4%, maps,the major improvements on this property fall in an
requirements of the local zoning ordinances in effect at �a '(+
the time of construction,or are exempt from violation �� GEORGE yes area designated as Zone.
enforcement action under M.G.L.Title VII,Chapter 40 a C /^
v � Community Panel No.
Section 7,and that there are no encroachments of major COLLINS Effective Date:
improvements either way across property lines except a. o-417 �Q
shown and noted hereun. P` NOTE:Zone C is areas of minimal flooding(no shading).
Q; This designation is not based on an elevation certificate.
NOTE:This is not a boundary or title insurance survey. is plan ccordance to procedural and technical standards for Mortgage Loan Inspections as adopted
by the Massachusetts Board of Registration of profes5ionat engineers and land surveyors,250 CMR 6.05,and use for any other purpose is prohibited.This plan is not to be
used for recording,preparing deed descriptions,or construction.