4 ARTHUR ST - BPA-14-289 FIVE WINDOWS 2-
The Commonwealth of Massachusetts
Board of Building Regulations and Standards C S
Massachusetts State Building Code,780 CMR SALEM
2016 AM 11, RAs4J432011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
D This Section For Official Use Only
Building Permit Number: Date Ap lied: '
A4� dd
Building Official(Print Name) Signature Date
I
SECTION 1: SITE INFORMATION
CL C 1.1 Property Adores 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. Owne�IA(c Aj L
Name(Print) T ��h"±{k City,State,Z'I1PIn�v r
No.and Street Teleepphhork ' Email Address
11 SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Or I Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Ot ❑ Specify:
Brief Description of Proposed Work2:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:Labor and Materials Official Use Only
L Building $ 1. Building Pemrit�Fee: $ Indicate how feeds determined:
❑ Standard City/Town Application Fee
2.Electrical $ s
❑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: $ 0 Paid in Full' 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
L Licen a Number ExptDte
Name of SL Holder
List CSL Type(see below)
N d Street Type Description
,r U Unrestricted(Buildings up to 35,000 cu.ft.
City/Town, tate, IP R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
Signeature '� WS Window and Siding
SF Solid Fuel Burning Appliances _
I Insulation
Telephone Email address D Demolition
5.2 Registed ome Im ov nt Contractor(HIC) /
T 400
HIC Registration Number Exp' do ate
HII. ie or 111C1C Registran
a n
Signature Email
Cit /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 Issuanc the building permit.
Signed Affidavit Attached? Yes ..........Er 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 ork authorized by this building permit application.
Print Owner's Name Signature Date
SECTION 7b: OWNER`OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the painsid penalties of perjury that all of the information
contained in this application is true and accurate to the b of p o vledge and understanding.
5W le %�
Print Owner's or Authorized Agent's Da
NOT S:
1. An Owner who obtains a buildingrmit to do is/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Impr vement 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. o_—�Information on the Construction Supervisor License can be found at www.mass.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 halfibaths
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"