6 AUBURN RD - BPA-08-153 REPLACE SIDE DOOR The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code,780 CMR, 7h edition OF SALEM
Revised January
Building Permit Application To Construct,Repair,Renovate Or Demolish a 1,2008
One-or Two-Family Dwelling
This Sect n Fo Official Use Only
Building Permit Nu er: Date A plie f ^�
Signature:
Building Commissioner/ffispector of Bu Idi Date
SECTIOV.SITE INFORMATION
1.1 Pro er ,ddress: 1.2 Assessors Map&Parcel Numbers
Lla 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
s
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 O( �ner of Re rd: rr v /� /� 1 c p /t A /)
vQh'P Qrrc%,in *On 1x 7-rUbc� ffl KOad vale MA
Name(Print) i Address for Service:
9h ?--7a9-H?Y0
Si a Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed WorV:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ 11 Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: 1i
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ a(0-6w' ✓�j 0 Paid in Full 13 Outstanding Balance Due:
Fi
p.
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
p^ IDQLIo - b I/
l-:2/C License Number Expiration Date
amL-Hol er
17 f/"CSA f, LJ�- . List CSL Type(see below)
AddT Description
U Unrestricted u to 35,0000 Cu.Ft.
R Restricted 1&2 Family Dwelling
St ire M Masonry Only
O Gv
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Reeistered Home Improment Coot for(HIC)
i/t-u�,ht9C1� �eR�S- �t�.�G. 6 7
HI Co gtration Number
Z{/ /�bV+ ati — O/4i/ N
Ad s / � Cg I J Zvl
w..c �,L�., ,.JL (� Expiration Date
Signature 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
JG0.K P 0.►ry-1 a O�oyl as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this buildin permit application.
I I )f l l)
Si of Owner Date
f SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
V Q K P_ �401,Ir 111 CT6 VI as Owner or Authorized Agent hereby declare
that the statements and informationjon the foregoing application are true and accurate,to the best of my knowledge and
behalf. �tL'�� L
0412 Tlariri 'For)
Print e _
—c I I 20 1 0
Signatu e Af Owner br Authorized Alcor Date
(Signed bqiVr the pains and penalties of 'u
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"