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BPA-17-241 ROOF �5 CK The Commonwealth of Massachusetts Board of Building Regulations and Standards '' ' Massachusetts State Building Code,780 CMR SALEM 811 MukglAftf2al'44 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only ® Building Permit Number: Date Applied: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Prop ty es : 1.2 Assessors Map&Parcel Numbers 17 I.I a 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 SuPP1Y (M.G.L c.40>§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: Outside Flood Zone? Public❑ Private❑ — Municipal❑ On site disposal system ❑ Check if yes[] SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record• ^ V L 1 Name P n�� At) Ci State ZIP . 7 No.and Street rTeleP one Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition 13 Demolition ❑ Accessory Bldg.❑ Nufnber 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 $ 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard CityJTown Application Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ f k 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Total All Fees:$ Suppression Check No. Check Amount: Cash Amount: y 6.Total Project Cost: $ S)D• 0) ❑Paid in Full ❑Outstanding Balance Due:_ �l rnPS.tLLk „ r SECTION 5: CONSTRUCT[ON SERVICES 5.1 Construction Supervisor License(CSL) © /1aP License Number Expiration Date Name of CS/L Holder List CSL Type(see below) L Type Description go.%d Street / U Unrestricted(Bui!dings up to 35,000 cu. tt. ?�,,2'' R Restricted 1&2 Family Dwelling Cityfrown,State,ZIP iM Masonry RC Roofing Coverin WS Window and Sidin SF Solid Fuel Burning Appliances S �� 1 Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) L V//'A- 4 n ,�'k r T�� HIC Registration Number Expiration Date FII- om any Name or Flue istrant Name 5r) P&W No. 'act�G��f �� /�0 Email address I City/Town.State ZIP Telephone SECTION 6:WORKERS'COdIPENSATION INSURANCE AFFIDAVIT(M.G.G.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 Wtrance of the building permit. Signed Affidavit Attached? Yes..........0 No...........13 SECTION 7a.OWNER AUTHORIZATION TO BE COMPLETED.WHEN, OWNEWS AGENT OR CONTRACTOR APPLIES~FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize - t9 act on my b Print Ownermatters relative to work authorized by this building permit application. 's Name(Electronic Signature) ate 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. 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�NI.G.L.c. 142A.Other important information on the HIC Program can be found at %v%vw.m:ss.eov'oca Information on the Construction Supervisor License can be found at vvww.mass.'oV/dns 2. When substantial work is planned,provide the information below: 'rota) floor area(sq. ft.) ,(including garage,finished basementlattics,decks or porch) Gross living area(sq. ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths 'fype of heating system Number of decks/porches 'fype of cooling system Enclosed Open 3. "Total Project Square Footage”may be substituted for"Total Project Cost"