BPA 17-261 SHED v t 2-S � � 1
Che Commonwealth of Massachusetts F I w '
ffv OF
UIE"
Board of Building Regulations and Standards SALENI
Massachusetts State Building Code, 780 CMR 1011 APR I RtseAlar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
(� One-or Two-Family Dwelling
This Section For Otficiai Use Only
_ Building Permit Number: Date App'
Signature
SECTION
Date
Building Otlicial(Print Name).
SECTION 1:SITE INFORNIATION
1.1 P operty Address: 1.2 Assessors Nlap 8c Parcel Numbers
DA WA-f
Map Number Parcel Number
I.1a Is this an accepted street?yes no
1.3 Zoning Information: 1.4 Property Dimensions:
`Luning District Proposed Use Lot Area(sq 11) Frontage(11)
1.3 Building Setbacks(ft)
Front Yard Side Yams Rear Yard
Required Provided Required
Provided Required Provided
1.6 Nater Supply:(M.G.L c.40,§S4) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
pp y� Zone: _ Outside Flood Zone?
Jg Private❑ Check if es❑ Municipal❑ Onsite disposal system C3Public
SECTION 2: PROPERTYOWNERSHIPI'
:2.1 'nerlwof Record: SA-�� MA O%A b
►� titnl
me Print) City,State,ZIP
t� f�iy1 A rSOK 1nl R1� ��-�
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repair (s) ❑ Alterntion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other >A Specify:
i
Brief Description of Proposed`York': 1rSt At.u. ' Z X t
SECTION 4: ESTIXIATED CONSTRUCTION COSTS
Estimated Costs: OfQeial Use Only
Item Labor and ivlaterials)
S I. Building Permit Fee:S Indicate how fee is determined
I. [3uilJin; :
❑Standard Cityriown Application Fee
2. Electrical S ❑Total Project Cost((tem 6)x multiplier x
3. Plumbing 'S 2. Other Fees: $
4.mechanical (EIVAC) S
List:
j. Mechanical (Fire ,S "notal All Fees:S
Suppression) Check No. Check Amount: Cash Amount:
6.T tai Project Cost: 'S ❑Paid in Full 13 Outstandin;Balance Due:
LAI 2 -asp Uri vt�t�
c - -TO N.o
i
C
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder List CSL'rype(see below)
Type Description
No.mid Street
U Unrestricted(Buildings tip to 35,000 cu. 11j
—
R Restricted 1&2 Farnily Dwelling
City/town,State,ZIP M Masonry
RC Roorina Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(NIC)
HIC Registration Number Expiration Date
111C Company Name or HIC Registrant Name
No.and Street Email address
Ci /Town State ZIP Telephone
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...........17
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 -
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 thisa tet n ais true and accurate to the best of my knowledge and understanding.
Print(hvner's or Srized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to Jo his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will Brut have access to the arbitration
program or guaranty fund under NLG.L.c. 142A.Other important information on the HIC Program can be found at
w%v%v.mass.,ov:'oca Information on the Construction Supervisor License can be found at wtv%v.mass.(ov'dns
2. When substantial work is planned,provide the information below:
'notal tloor area(sq. R.) (including garage,finished base men t/attics,decks or porch)
Gross living area(sq.11.) 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 Enclose) Open
3. "Total Project Square Footage"may be substituted for"notal Project Cost"
Professional Land Surveyors Et Civil Engineers
ESSEX SURVEY SERVICE. 1958 - 1986
OSBORN PALMER 1911 - 1970
BRADFORD 8 WEED 1885 - 1972
PLOT PLAN OF LAND
LOCATED IN
MASS.
ii• 20
-A0
ANOIJA GVH y
I hereby certify to the
ZONE: 2 f LOT AREA: LOT FRONTAGE:. �U�iL Building Inspector that the pro-
posed construction shown conforms
FRONT YARD: 16h SIDE YARD: kr-7- REAR YARD: 3Gj-'/ to the dimensional zoning of
SCALE l �� 2L =f�'/ Mass..
2 / rlLr �'
DATE: APf2�/ 20/2
RISTOPHER
REFERENCE: p[ BK U L PG /"/ Chr stopher R. Melly PLS 117
airs +.
No.31317 O ,;
104 LOWELL STREET `,A
PEABODY, MASS.01960
(508)531-8121
FAX:(508)531-5920