38 BUCHANAN RD - BPA-16-868 IS� Gb cc-
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Commonwealth of Massachusetts Eli �f
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code,780 CMR pppph ���
00 Building Permit Application To Construct,Repair,Renovate Or Demo is, au
One-or Two-Family Dwelling
WBtt Perms iffier . nate e1:
(P n N nie) Signature DRi
1 aCTfON 1:srrE o> nTlOiv
1.1 PropertyAddress: �D 1.2 Assessors Map&Parcel Numbers
3 a AyC_VnOtv�a v.
1.1 a Is this an accepted street?yes no_ Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot'Area R) Frontage(II)
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:
Zone: _ Outside Flood Zone? Municipal❑ On site al stem ❑
Public❑ Private❑ Check if 13 P disposal sy
SECTION 2: PROPISRTYO",,V, SII#Pt
2.1 Owner of Record: - 2 M m�, 615-70
STEu6 i SEK I Sctl
Name(Print) R,141 A• City,State,ZIP
38 Gy(ha V%A ys 9 qLZ) t I-4f 26�
No.and Street Telephone
Email Address
SECTION 3:DESCRIPTLON OP PROPOsMED WORK'(iheck all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) O 1 Alteration(s) ❑ Addition ❑
Demolition ❑ I Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Worle: h< Uorwnev' IYJAG of S
O
SECTION 4:ESTMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item abor and Materials
1.Building $ a I 7 Lf 1 . 6 I, Building Permit Pew.$ Indicate how fee is determined-
O Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees.-
4.
ees:4.Mechanical (HVAC) $ List: _
5.Mechanical (Fire $ Total All Fees:$
Su ression
u Check No. Cheek Amount: Cada Amount:.
6.Total Project Cost: $ Z /I. 6 O Paid in Fall 0 Outstanding Balance Due:
5cv0 -t n +-1 . o . L mRltrli�- I6
7 G>ta W)I4 B(aL
18 l - Zia-1"l0-�
SECTION 5: COMTRUCrMIRERVIC0
5.1 Construction Supervisor License(CSL) ?q Lf /fig
oin AC L 1'S�y� License Number Expiration Date
Name of CSL Holder
2c �� List CSL Type(see below)
No.and
,S,treetn/ t,�
J�•�`'t A'�_01T \ 1 RriJ C) \CL 6, (UN I Unrestricted
Restricted M2F(Buildingsmily�in 000 cu.ft.
City/rown,State,ZIP M Masmy
RC I Roofing Covering
WS Window and Siding
�..9, _q ►Q SF Solid Fuel Burning Appliances
t S I I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
12008 Z 1.,51A-11 7
T�dmAS TUC Registration Number EVnmhcnDate
HIC CompanxNnme or IBC
CRegis[rant Name
((meq V' LL
No.and Street M(-) 0467 ��_�yg�j 318 Email address
SUC est:
Ci frown State ZIP Tel hone
SECTION r"WORKERS'COMMMATION INSURANCE AFFIDAVIT(NLG.L c.152 4 25C(49)
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...........❑
SEt�161�fi 7a OWNER AUTHORJZ—A11ON TO B$C6?—&LETEA WIZEN
ORNER'S AGEAI I C9 CTQ3t F $ Pq{a
I,as Owner of the subject property,herebyauthorize1 hoeOH S E On vF s
to act on my behalf,in all matters relative to work authorized by this building permit application.
# STev� I SE K I /� •Tits+[ {}trT 3 20► 6
Print Owner's Name(Electronic Signature) Date
SECTION 76:OWNEW OR AUTHORMI)AGENT MCLARATION
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.
ai
1 �4tom F [ Ari :S 653
1pt 6
Print Owner's or Authorized Agent's Name(Electronicsignature) Date
NOW
1. An Owner who obtains a building permit to do his/her own work,or an owner who hives 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 TUC Program can be found at
www.mass.¢ovloca Information on the Construction Supervisor License can be found at MM .mass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch)
Gross living area(sq.ft.) 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"
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