3 SYMONDS STREET BPA-17-113 E�;Nk L
The Commonwealth of Massachuse(
Board of Building Regulation F Ea 23 P 14. �ITY OF
Massachusetts State Building Code,780 CMR SALEM
I Ret ived Mar 201
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One- or Tsi-o-Family Dwelling
This Section For Official Use Only
Building Permit Number: plied:Date, plied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1,to Is this an accepted street'!yes_--Y, no Map Nunitcr Parcel humtrcr
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Arca(sq 0) Frontage(11)
4
1.5 Building Setbacks(ft)
Front Yard Side Yards, Rear Yard
........... T-
Required I Provided Required Provided Required Provided
1--.6 Water Supply:(M.(;L.c 40,§S4) 1.7 Flood'Lone Information: 1.8 Savage Disposal System: V#
Public 0 Private 0 /10? Zone. Outside Flood Zone? Municipal 0 On site disposal system 0
Check if es[&'—
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
SALQIA-k MK C)iq
Rifric(Print) City,Stair,ZIP
No and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
T
-J'Alt, -1
up d M R-epai I on" Addition
IN
Nc%v Construction 2 Existing Budding Of!!5�70cc 'c rs 5
Demolition 01 Accessory Bldg.C& Number of Units Other 0 Specify,
Brief Description of Proposed Work 2:q--u-"2,tqhP-.5�— IV JLVr-
A19b
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:-'T'
(Labor and Materials) offilcial Use Only
1.Building 5 1. Building Permit Fee: Indicate how fee is determined:
0 Standard City/Town Application Fee
2 E lectricil
- 0 Total Project Cost 3(item 6)x multiplier x
3.Plumbing S 2, Other Fees: S
4.Mechanical (IIVAQ $ List:-
hanical (Fire S Total Ail Fccs 'S'
Sup re si!?n
re
Check No Check Amount: Cush Amount
Total Project Cost: $ 5U 0?1l
0 Paid in Full 0 Outstanding Balance Due:,,___
Mkk<e L 6 rw s %/ooze7A%-- n,p
SECTION 5: CONSTRUCTION SERVICES
51 Construction Supervisor License(CSL)
1 11 i ---1
ctrl Ic E x ipl,
to Date
Name tkck mocr ctrl
Lml CSt.Type(sectrclow) _0-
hi) anti socc; t TY Dcscnpnon
J)" -Unrestricted(Buildings up to 35,000 cu ft
-S 1-, 4/.e ea -7. R Restricted 1&2 Family DAelling
Cny/Town,Stile,ZIP M -Masm
RC -Roofing Covering
WS Window and Sidin
SF i Solid Fuel Burning Appliances
"; Insulation
Tee [-mail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
[I(( Registration Nurntxr Expi ation"baic
IfIC Company Name or,111C Repiswin Name
-4 >, Lei-'t C v-)r4.iekfc--ly
No.and Slicer Finast address
drat r +r( e,-T 0 S-,
-
Citv/Tovvir,;tate,7,IP 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 Issuance of the building permit_
SignedAffidavit Attached! Yes". No..........0
SECTION 7st:OWNER AUTHORIZATION TO HE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,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 Ounce's Name(Flectrooic Sigim(urc) Date
SECTION 7b;OWNEWOR AUTHORIZER AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all ofthe information
contained in this application is true and accurate the best of my knowledge and understanding.
—C-1-1 4
Print Owner's or Authorized Agent's Natne(ElcWrilo-ic Signature) ate
NOTES:
I An Owner who obtains a building permit to do hislber own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(1-11C)Program),will"o 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
Information on Lite Construction Supervisor License can be found at
1 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 11) habitable room count
Number of fireplaces Number ol'bedrooms
Number of bathroom: Number of halPbaths
Type of heating system Number of decks%porches
Type ofcooling system Enclosed
Open tj
3. "1 otal Project Square Footage"may be substituted for-Total Project Cost"
. f
t
I ` 3
a
3
at
• 6
NOTE: 1 HEREBY CERTIFY TO THE BEST OF MY KNOWLEDGE THAT THE NOTE: THIS IS A TAPE SURVEY NOT TO BE USED FOR ESTABLISHING
PREMISES SHOWN ON THIS PLAN ARE.NOT LOCATED,WITHIN.THE. PROPERTY LINES, HEDGES, OR ANY..PURPOSE OTHER THAN ITS
FLOOD,HAZARD ZON AS DELIIJE&TED ON THE MAP OF COMMUNITY ORIGINAL INTENT. THIS PLAN WAS DRAWN FOR MORTGAGE PURPOSES,
r rm I 4A.G. MASS. ONLY. NOT TO BE RECORDED.
EFFECTIVE BY THE DEPT.OF HOUSING
AND URBAN DEVELOPMENT-FEDER4 INSURANCE ADMINISTRATION, THE LOCATION OF THE DWELLING AS SHOWN HEREON EITHER WAS IN
COMPLIANCE WITH THE LOCAL ZONING BYLAWS IN EFFECT,tWHEN.. .
CONSTRUCTED (WITH RESPECT TO STRUCTURAL SETBACK
I CERTIFY THAT THE BUILDING SHOWN ON THIS PLAN IS ON THE REQUIREMENTS ONLY),OR IS EXEMPT FROM VIOLATION ENFORCEMENT
GROUND AS SH WN. ACTION UNDER M.G.L.TITLE VII,C.40A,97.
MORTGAGE INSPECTION PLAN
e� Ga L.G.BRACKETT COMPANY,INC.
o< :TALMADGE WINCHESTER,MA
McNEELY IAPLANOF PROPERTY IN SCALE: 1
i#22594 - ---
Fss�0I/A LAN�'�� OWNED BY r DATE: -�6
COUN VC 1 CERTIFY THIS PLAN TO DATE OF PLA :
PLAN: _ '
PLAN B —