BPA-17-251 KITCHEN REMODEL c-Koq� �
s� The Commonwealth of Massachusettsp 1;4i� ITYOF
Board of Building Regulations and Standafd�'ECDOHA.L SEV �: . ASALEM
Massachusetts State Building Code,780 CMR
Revised Mar 2011
Building Permit Application To Construct,Repair,Renov&bAR&rhJiis* 44
JQ One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date App .
' Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Propertyddress• 1.2 Assessors Map &Parcel Numbers
65 Ga(togE U I I . Rd
1.1a Is this an accepted street?yes—Y 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❑
p � SECTION 2: PROPERTY OWNERSHIP)
2.1rQnY1�1 Q S RJ C-G�1'1'1 t°✓` J 0. arn
Name((Print) City,State,ZIP
56 &!le w5 dill Rd MJ �-r;T�.� z a3 y�
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WOR]e(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied 0( 1 Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work- :
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ Zoo pU 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ 0 ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
r\,t,�Fo Lk I l7- Tb µ C>.
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) W—O FT 20 6
I` AY` ` r
��� License Number Ex tion Date
Name of CSL Holder L/
,76 14
/Y� A � c � 2� � List CSL Type(see below)
No.and Street /`l, c, / Type Description
/�m I,�„ / v U Unrestricted(Buildings u to 35,000 cu.ft.
�'�1 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
97XoZc)(? Y y6 `maci4illCyr484.Cu IF InsulationSolid )Burning Appliances
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) /S31-743' �/////7
701", 14 V,e-v— i/ HIC Registration Number Expiration Date
HI Cmpany Name or HIC Registrant Name
0 )9- cru� 72 es c� n P //157 c)
No f R1rtp Email address
City/Town, 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 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
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
11 SECTION 7b: OWNERI OR AUTHORIZED AGENT DECLARATION
\A'pteri ''i�y e elow,I hereby attest under the pains and penalties of perjury that all of the information
cont' ed i 'sap 'ca 'on is true and accurate to the best of my knowledge and understanding.
Print Own 's�or Authonzed Agent%N ctronic Signature) ate
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
cv�vw.mass.gov/oca Information on the Construction Supervisor License can be found at Nvww.mass.gov 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"may be substituted for"Total Project Cost"