0010 PURCHASE STREET BPA-17-121 The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALENI
Massachusetts State Building Code, 780 CMR Revised,thir 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family D►velling
This Section For 91ficial Use Only
r Building Permit Number: ate Applied:
J.
Building Official(Print Name). Signature Date
SECTION 1:SITE INFORMATION'
y� 1.1 Property dress- 1.2 Assessors,Nlap&Parcel Numbers
L l a Is this an accepted street?yes no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
"Luning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Nater Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal E3 On site disposal system ❑
Public-0— Private❑ Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 1 hers'f Record:
NN me(Print) li r City,
7ta /
State,ZIPP�
/f1 ��Li�/CCS /t� ? 72
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKi(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alterntion(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units I Other ❑ Specify:
Brief Description of Proposed Work-: !'
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials)
I. Building $ ab Dam 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ O Total Project Cost(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mcclumical (11VAC) S List:
5.Mechanical (Fire "fotal All Fees:S
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cust: ❑Paid in Full ❑Outstanding Balance Due:
VV1a► e, Z.'Z9r Tb K .p .
j
SECTION 5: CONSTRUCTION SERVICES
5.1 Con truction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder list CSL Type(see below)
Type Description
No.mid Street
U Unrestricted(Buildings tip to 35,000 cu. It.
R Restricted I&2 F:unil Dwellin
Cityfrown,State,ZIP M IMasonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IIIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /Town State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.i»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...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN:
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERAIIT
1,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 its.pplication is true and accurate to the best of my knowledge and understanding.
Print wner'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 not have access to the arbitration
proram or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.1 ov'oca Information on the Construction Supervisor License can be found at ww%v.mass.sov'"Ins
2. When substantial work is planned,provide the information below:
'notal floor area(sq. ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
type of heating system Number of decks/porches
f ype orcoolina system Enclosed Open
3. "Dotal Project Square Foota;e"may be substituted for"Total Project Cost"