BPA-17-217 EXTERIOR WORK I I 5 Ole
The Commonwealth of Massachusetts ° '' t NQS. SE "Y
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CW
SALEM
11 MSIR 28 P rm&Mar 2011
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 plied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
11 rty Address- 1.2 Assessors Map&Parcel Numbers
�+ 1.1a 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 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 Ownerl gf Recid:
2 k� 1 V lyYL �G2/&?n
Name(Print) City, tate,ZIP
,18 haf-b2l`
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WOR10(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s)X Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2: I rl ( yxIl'' CV J C_
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials
1.Building $ g4w1. Building Permit Fee;$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) 'Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $, l �i 13 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor Lic ase(CSL) 57 40 (y /G
[3� m License Num er Expiration Date
Name of CSL Huller list CSL Type(see below)
Description
No.and Streit I U Unrestricted(uuildings a to 35,000 cu. It.
R Restricted 1&2 Family Dwelling
Ag—
CW.ty(ro—,Qvn,State,Z1P ivt Masonry
RC Roolinst Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
hll ep,��m ot7 .(, 1 Insulation
ele hone Email address D Demolition
5.2 Registered HomeMVproveWent Contractor(HIC)
)') h e(\ ` HIC Registration Number Expiration Date
If any Name orA11C Re ' nt Nagy j fabd C ' Q Wim.
No.an S Email a ress
Ci /Town State ZIP 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 Is§uance of the building permit.
Signed Affidavit Attached? Yes .......... No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED.WHEN..
OWNER'S AGENT ORCONTEtACTORAPPLIUFORBUILDING PERMIT
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 this application is true and accurate to the best of my knowledge and understanding.
Print Owner'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 nu 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
%vww.mass.eov!oun Information on the Construction Supervisor License can be found at www.mass.-ov/dL
2. When substantial work is planned,provide the information below:
'focal 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 Foota;e"may be substituted for"Total Project Cost"