0044 VALLEY STREET BPA-17-205 The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code,780 CMR SALEM
• ,� i Revised Mar 2011
l�J Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Da plied: 312-1117
Building Official(Print Name) ISignature Ddte
SECTION 1:SITE INFORMATION
1.1 Proope ddress: 1.2 Assessors Map&Parcel Numbers
Mt_c C
1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 ZRAmng Information: 1.4 Property Dimensions:
/fit
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'
2.1ner'of Record:
/Z/*&
Name(Print) City,State,ZIP
11y J146Lit S T7Y ?Vf-oiyy
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing BuildingRr Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work2: /,rs,io« L ori 0 U, efW C_4tie 94g'-? 'Ji' 90J
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 3Ze11). 1• Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost(Item b)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $3 S Cr-0 Q 13 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCP[ON SERVICES •`�
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL(folder
List CSL Type(see below)
Type Description
No.;uid Street
U Unrestricid(BuildingS LIP to 35,000 cu. It.
R Restricted l&2 Family Dwelling
City/town,State,ZIP M Masonry
RC Roo ling Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
I Insulation
Tcle hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
MC Company Name or HIC Registrant Name
No.acid Street Email address
Ci /Town State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.152:g 25C(Qy .
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 OR CONTRACTOR APPLIES FOR BUILDING.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 a to to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's ane(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 cru 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
www.m:ss.wWoca Information on the Construction Supervisor License can be found at ty%vw.niass.1ov/dys
2. When substantial work is planned,provide the information below:
"total fluor area(sq. R.) '� (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 dumber 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"