BPA-17-249 ROOF 4
ti
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling o
{ This Section For Oficial Use Only
V Building Permit Number: Date Applied: �o ,
O
Building Official(Print Name) Signature '
r SECTION 1:SITE INFORMATION '
1..1�/P�roperty Address:_ 1.2 Assessors Map&Parcel Numbers W
L la Is this an accepted street?yes 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 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'
2.1 Owner'of Record:
t 12t v( CJ r3etf-,J 5ALk-0% mot 01176
N P nt) City,State,ZIP
3 a M(e*V4 4-L- 01z, x2911-'716 - S 3
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building VL, Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2: f.c GJG 0*61k L
CE 'td 64 5 4IkL4t3,t'j+✓� IL i c if
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ �} y 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $
r-3StandardCity/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 9,00� � ❑Paid in Full ❑Outstanding Balance Due:
Mate yl lZ
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SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) Xw � �(a (lG
-License Number Exp ratio Date
Name of CSL Holder List CSL Type(see below)
Ls�t�✓P- Type. Description
No.and Street U Unrestricted Buildings V to 35,000 cu. 1.
,A�GD�J 01 a b C) Restricted 1&2 Family Dwelling
City/Town,State,ZIF 'hill IV
Rootinit Covering
S Window and Si in
SF Solid Fuel Burning Appliances
• _ I Insulation
Telephone Email address Demolition
5.2 Registered Home Improvement Contractor(HIC) A G t7'7
�,k)fk Ct� ayL HIC Registration umber Expiration Date
F lIC Con any Name o(I C Registront Nae
tt.rJAt.1l)
�Street Email address
No.a
Street VG
Ci frown State ZIP Tele hone
SECTION 6:WORKERS,.COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.MI.$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 ..........)d No...........0
SECTION 7a.OWNER AUTHORIZATior4 TO BE COMPLETED,WHEN.
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING.PER UT
1,as Owner of the subject property,hereby authorize -
t9 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,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.
Print Owner's or Authorized Agent's Name(Electronic Signature) ate
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 NI.G.L.c. I42A.Other important information on the HIC Program can be found at
www.mass.eo�!oca Information on the Construction Supervisor License can be found at w%aw.mass.gyov/u s
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"may be substituted fur"Total Project Cost"