UNIT 2, LAUNDRY BPA-17-142 4Llp �s
The Commonwealth of Massachusetts
Board of Building Regulations and Standards
Massachusetts State Building Code,780 CMR SALEM
Building Permit Application To Construct,Repair,Renovate Or t$0i8A9h ab kviydit 2011
1 v One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
I Building Official(Print Name) Signature Date
CQ SECTION 1:SITE INFORMATION
1.1 Property Address:
y5 ocg*NAvi✓ 001-r1.2 Assessors Map&Parcel Numbers
2 t'S11
1.1a Is this an accepted street?yes ✓ no Map Number _ bParcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft) 4
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required 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?
Check if es❑ Municipal❑ On site disposal system 13
SECTION 2: PROPERTY OWNERSIIIPi
2.1 Owners of Record:
A NVReV GAY N£ 5mem, +Mr,S o iq�i6
Name(Print) City,State,ZIP
75 NA-*, VW 2- Wto-378-20 A-+ ftYfJ6At1&&o4141-•Caw1
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) Mr Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other [3Specify:
Brief Description of Proposed Work-2:_ c6mmMr ex i,5+rk 4 clonic['i-o 5,f AcK+4 V6
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials Y
1.Building $ 5 a» 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ b ❑Standard CitylTown Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ /�.� 2. Other Fees: $
4.Mechanical (HVAC) $ List: --�� -
5.Mechanical (Fire $
Suppression) Total All Fees:$
ao Check No. Check Amount: Cash Amount:
r6.Total Project Cost: $ ��. ❑paid in Full p Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 0A541ZS y--24-17(7
-PWn A04txt' se Number Expiration Date
Name of CSL Holder
12 ;A�AI 6T, List CSL Type(see below) {�
No.and Street Type Description
U Unrestricted(Buildingsu to 35,000 cu.ft.' lei R Restricted 1&2 FamilyDwelling
City/Town,State,ZIP M Maso
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
111GxlijeV4006-ezm I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
A"ipl/W 4&y 2 ;1/Mn f*Nft1 1YS6X77 l�
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
V2 ff7ruc66N sT Aimx*r **tc bo6w,4Yea, 1
No.and Street Email address
'"M\l, AA, of%� �t-e-(z7-67
Ci /Town State,ZIP - Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.g 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.
Signed Affidavit Attached? Yes ..........1� No...........❑
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 ��� �UPh►r>:a1 fA� ptrtrtc�t�FIy
to act on my behalf, in all matters relative to work authorizedy this building permit application.
A'i J r L P 4 4 4 C. /! a,Ci4 �, dot 7
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'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 this application is true and accurate to the best of W knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) ?Autxl Date
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 not 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
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.iiiass.gov/dps
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.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
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"