BPA 17-277 NEW DECK & ADDITION The Commonwealth of Massachusetts=
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Board of Building Regulationsli iAS s L t CITY OF
Massachusetts State Building Code,780 CMR SALEM
--�� Revised Mar 2011
Building Permit Application To Construct,RIJ11,01AMe&JIM: 9lish a
Rte` One-or Two-F mily Dwelling
�-� This Section For Official Use Only
Building Permit Number: Date pplied:
Building Official(Print Name) Signature Date
_ SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
14s �=6�t �Jemtie as Yy— cCOg
l.la Is this an accepted street?yes_x_ no Map Number Parcel Number
` 1.3 Zoning Information: 1.4 Property Dimensions:
Pi-1
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
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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:
Me'i,CA Connell Salem +'1'I 0lq,lG
Name(Print) City,State,ZIP
i,6 Fu(t /IVMUC �o8-tti��-lc i� (11�'C�nnef ���!'crrlcust,
No.and Street y Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction j8( Existing Building❑ Owner-Occupied �i( Repairs(s) ❑ Alteration(s) ❑ Addition J4
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description oS Proposed Work2: /1!e uU Ci,,A< hlLtC-l'u Y, a 00 C 6,nc-J w
r u:'d I Au-r u e 'c - r
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials
1.Building $ 6,6 C, 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
000 ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ -,
ppb 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ ( Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 17 �Q(J(� 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number F,rcpiration Date
—1T_ _ fli-
c5 - IQ 365 f
Na of CSL[[older r n ` List CSL Type see below)
Type, Description
No.and Street U Unrestricted Buildin tip to 35,000 cu. R.
R Restricted U2 Family Dwelling
City/To% , tate,ZIP M Masonry
RC Roolinit Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) _(�LA-:� �
G tal Cr'v-)n 4QRe NHIC Registration Number Expiration Date
[IIC Company N e or HIC Registrant a e
ata Strecok ) non Ci
etEmail address
r;-r--, nC�.ii (�l'� G1c1Co.0 a�� ���i .B►O��
Ci /Town Sta a ZIP
Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.g 2$C(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..........E3 No...........O
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 G QZ 6.(A' 41y10, LbntNC U n _
Lacton my behalf,in all matter relative to work authorized by this buildin ermit application.C, G /'
Print Owner's Name(Electronic Signature) ate
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the p ins and penalties of perjury that all of the information
co in ip this application is u and accurate to the b st of my knowledge and,tlgderstanIng.
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Print Owner's or Aur horized Agent's N• cctronic Signature) f. 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 nu have access to the arbitration
program or guaranty fund under 1M.G.L.c. 142A.Other important information on the HIC Program can be found at
%v%vw.mass.eov,'oca Information on the Construction Supervisor License can be found at%v%vw.nstss.,ov!dos
2. When substantial work is planned,provide the information below:
'notal floor area(sq. it.) I AN '' (including garage,finished basementtattics�decks or porch)
Gross living area(sq.tt.) Habitable room count
Number of fireplaces / Number of bedrooms 3
Number of bathrooms 3 dumber of half/baths ,0
Type of heating system Number of decks/porches
'type ofcooling systein QA Enclosed ,Pl Open
3. "'Total Project Square Footage"may be substitute) for"Total Project Cost"
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