0011 OAK STREET BPA-17-209 1�
The Commonwealth of Massachusetts10 r;iu
Board of Building Regulations and Standards ' NALCW,'Q v =
WMassachusetts State Building Code, 780 CMR SALEM
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vise r2011
Building Permit Application To Construct,Repair,Renovate Or DerAlJhVR 21 ( 5
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 Property Address: 1.2 Assessors Map&Parcel Numbers
l.la 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 Owner'of Record:
Name(Print) City,State,ZIP
13, N3 M/A
No.and Street elephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Building ,0 Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
fj►:.GC1�D Brief Description of Proposed Work2: 4:
UCIAKbJ , E .i- R EP LANCE E-M 17c I N4 W 1 N 0A& W MA 1-A Vr-Y
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SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ i Z-;Co 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $
❑Standard City/Town Application Fee
t ens
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ ILI 4c)d> 2. Other Fees: $ r
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ! 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) O 15j`3 3
W i t-L I AAA W161 LA A License Number Ex4ppirati4onte
l yj
Name of CSL Holder tJ
_ List CSL Type(see below)
tJ 1 k-MA A Type Description
No.and Street
U Unrestricted(Buildings no to 35,000 cu. It.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP bf 1\4asomy
RC Rooting Covering
WS Window and Siding
Ver I ass SF Solid Fuel Burning Appliances
9 t-7 S ,e 3% t 6 t!�l 6 tYwv c Ag:t I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) /�Q'3g 3
\Af I l-U AM \A/ 44 0A iZP ekM LY HIC Registration Number Expiration Date
111c
IComputY
NuJ�! �lgistr nt ma
a A 4 �7, Q S-7� Email address
Ci /Town State ZIP �v�t 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 Istuance of the building permit.
Signed Affidavit Attached? Yes ..........A No...........0
SECTION 7a.OWNER AUTHORIZATION TO BE COMPLETED,WHEN:
OWNER'S AGENT OR CONTRACTORAPPLIES'FOR BUILDING PERMIT
I,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 71b: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.
k�cF3�lt l
Print Owner's-or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or art owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will Mu have access to the arbitration
program or guaranty fund under I.G.L.c. 142A.Other important information on the HIC Program can be found at
\vww.nmss.gov!oca Information on the Construction Supervisor License can be found at www.niass.sov-'dns
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. tt.) 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"