BPA 17-273 RPR BACK PORCHg
The Commonwealth of Massachusetts R , ` R. . x
Board of Building Regulations and Standards
SALEMLEM
Massachusetts State Building Code, 780 CMR
I ie xr 2 11 t: 5 }
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 Appl' d:
I
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1 1
11 *KO\21-57 AVC I/
1.1 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 I 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:
1 40f3 IL2 C M rV1A 61077v
Name(Print) City,State,ZIP
r I -tC>rZ 57 4L f q7% 3 17 !,Aa Q
No.and Street 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. 1 Number of Units I Other Specify:
Brief Description of Proposed
Work2: 24 Ai t T51\CL— 16af1C P wi +—h A,-e--,,
OIL J d JAbC h
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:
Standard City/Town Application Fee
2.Electrical Total Project Costa(Item 6)x multiplier x
3.Plumbing 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Total All Fees:$
Suppression)
Check No.Check Amount: Cash Amount:
6.Total Project Cost: $ 3Paid in Full Outstanding Balance Due:
p c5b—D
7-6 C-'ow
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
C S 4C)?0 3 License Number Expiration ate
Name of CSL Holder UListCSLType(see below)
Type Description
No.and Street
5
U Unrestricted(Buildingsa to 35,000 cu. It.
a l!` R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP aNf Masonry
LRRooflngtCovering
4/ Z WS Window and Sidi n
SF Solid Fuel Burning Appliances
51, s- C/ 3 1 Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
0/22 khr
111C Registration Number Expire on Dane
HIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /Town State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.Q.L c.15L¢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 lsivancq4t the building permit.
Signed Affidavit Attached? Yes .......... No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED,WHEN:'
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING.PERhIi!T
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:OWNER'OR AUTHORIZED AGENT DECLARATION
Dy entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this app)ica on is true and accurate to the best of my knowledge and understanding.
olr 9113117
PrintOwner'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 art 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 NI.G.L.c. I42A.Other important information on the HIC Program can be found at
www.mass.,,ov'oca Information on the Construction Supervisor License can be found at www.massj-tovhlus
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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.tt.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
fype of coam,system Enclosed Open
Total Project Square Footage"may be substituted [or"Total Project Cost"
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