0005 SKERRY STREET -BPA-17-203 NEW STAIRS TO 2ND FL UNIT5 t
The Commonwealth of Massachtis`ettac CITY OF \
Board of Building Regulations and Standards I
Massachusetts State Building Code, 7SALEM
7D 17 23 P Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a z
OOne- or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Datep ied:
1
Building Official(Print Name) ignature Date
SECTION 1:SITE INFORMATION
1.1 Property Addre�s: 1.2 Assessors Map&Parcel Numbers
1.1 a 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 Di posal System:
Zone: _ Outside Flood 7
Public ,one?(2( Private❑ Check if yes Municipal On site disposal system 11
SECTION 2: PROPERTY OWNERSHIP'
2 Owner'of R rd:
1.'rl �ar� V114—' f em b�l�e 1 e t, 03.357
Dame(Print) 1 City,State,ZIP
9 Moun Eden Ou-e
Nd.and Street Telephone mail Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I.Other Specify:
Brief I�escrip 'on of Proposed Work': G UDS 2 G i
n �• ��►l vac Ins 11t`n
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ S'r�j(� Ud 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2.Electrical $ a
❑Total Project Cost (Item b)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: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) �-1 r v 0 f Y, l
Rr vo,n'J. L c Ado n License Number Expiration Date
Name of CSL Holder
9 O A Uo-�,1 r, Q v� List CSL Type(see below)
No.and Street ( I Type Description
1�2m /,� � �1� Unrestricted(Buildings u to 35,000 cu.ft.)
Y CY Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
/�
I SF Solid Fuel Burning Appliances
791706 V06 br��(t0 1�„ 10o'1i�1rx-•con I Insulation
Telephone Email address D Demolition /
5.2 Registered Home Improvement Contractor(HIC) 1
lr(9n &� Registration
a 1
HCCo pany me CRegistrantName HIC Registr�at�ion(yNumber Expiration
pIi�ration.
Date
T1ounI'b Je c
1309- Y) 66A067holoblac-cc)#n
,tynStrrp VZ-�Jt! 7811-��0 G
CEmail address
JCity/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 Issuance 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 PERMIT
I,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 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.
�'I-lin c U 3 /V/7
Print Owner's or Authorize gent's Name(Electronic Signature) 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
- ww_mass.ilov%oca Information on the Construction Supervisor License can be found at u_wvw.mass.gov!dris
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"
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