3 BERTINI LN - BPA-11-499 INSULATION all)
The Commtinweallh ot'Massachusetis
} Board of Building Regulations and Standards CITY
Massachusetts State Building Gale, 780 CMR, Tx edition OF SALEM
Revised Juni ury
Building Permit Application To Construct,Repair, Renovate Or Demolish a /. ZnlhY
(Jnr-orTivo-Fa 'Iv Dwelling
This Sectionkod Official Use Only
Building Permit Num r: a pp 'ed:
ffSignature: 4t-7w 7)Jill)O
Building Commissioner/1 tar of Buildings Date
SECTION 1:91TE INFORMATION
I.I Property Address, 1.2 Assessors Map& Parcel Numbers
3 Loi/
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 Aura(sq R) Frontage(Il)
1.5 Building Setbacks(R)
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:
Zone: _ Outside Flood Zone?Public❑ Private❑ Check-if es❑ Municipal❑ Onsit
e disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'o ecord:
Name(Print) Address for Service:.
�� y6�� 928- - -)yy-73 63
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKS(ctiack,all that apply)
New Construction O `Existing Building❑ 1 Owner-Occupied ❑ -Repeirs(s);❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 1,6 .
ther; ❑ Specify_:
Brief,Description of Proposed Work': T S
r a-.� . Ce.11klcSQ _ cJalf (_�-,3 -Jo • .Ca.l, Ile-
SECTION 4: ESTIMATED'CONSTRUCTION COSTS
EstimatedCost's:
Item Of11cIaI Use.Only
Labor and Mat
1. Building.,/ S 1. Building Permit Fee S.Indicatehow fee is determined:
:.Electrical S O Standard CitylTown'Application Fee
❑Total Project Cost (Item 6).x multiplier x
3. Plumbing $ 2. Other Fees: S
4. Mechanical (HVAC) $ Lisa
5. Mechanical (Fire S
Suppression) fatal All Fees:S
Check No. Check Amount: Cash Amount:_
6. Total Project Cost: S 66 C6 . 66 ❑Paid in Full ❑Outstanding Balance Due: