42 ESSEX ST - BUILDING PERMIT AP The Commonwealth of Massachusetts RECEIVED
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Board ofBuilding Regulations and�'t�a�dfa�ds1LisF1L SER u1D S CITY OF
1,1 Massachusetts State Building Cade, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,RAUM25err oo isl� 5
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Dat pplied:
.�.,,.a�trnnt Nam Signature 1% Date
SECTION 1: SITE INFORMATION
Y 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
ST-
I.1 a 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 Owner'of Record:
"&r+r sA�41,,1 M?< al 9 7 d
Namc(Print City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: SC- -RIN OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
L Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑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: $ L11-100. ❑Paid in Full ❑ Outstanding Balance Due:
1'V1 R t LAY, To cetJ T • 17- '�
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 'O16 40
O
1 ) .7 z. !e J' [tet/�, y-L License Number Exp oiLD.
Name of CSL Holder
List CSL Type(see below)
�e��•9 �� L
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
Q f/yGt.✓O/1 R Restricted 1802 Family Dwelling
'U City/Town,State,ZIP M Mason
/ ry
RC Roofing Covering
WS Window and Siding
9 SF Solid Fuel Burning Appliances
I Insulation
J
Telephone Email address D Demolition
5�.2 Re istered Home Improvement Contractor(HIC)
u5 �A-fit, MollR !? i�
�1 HIC Registration Number Expiration Date
F IC Company Nameor HIC Registrant Name
�4 ( h/
o
v
d S[
0�1 /6� Email address
O ' (�
Ci /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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No........... ❑
V
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES
JFOR
/BUILDING PERMIT
I,as Owner of the subject property,hereby authorize (,r bn
to 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: OWNER' OR AUTHORIZED AGENT DECLARATION
By enteri y name below,I hereby attest under the pains and penalties of perjury that all of the information
con tai e n this application i, curate to the best of my knowledge and understanding.
Pri Owner's or Authorized Agent's Name(Electronic Signature) Date
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 can be found at
www.mass.,gov/oca 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 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"