0001A FLETCHER WAY - B15-1261 . . i
r . 7
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CrrY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
N Building Official(Print Name) Signature Date
—1 SECTION 1:SITE INFORMATION
f� .1ProneAodre1.2 Assessors Map&Parcel Numbers
i1.1 a Is this an accepted street?yes no Map Number Parcel Number
(� 1.3 Zoning Information: 1.4 Property Dimensions: , z
�J m Ln
l Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) y m
` 1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
UJ >rn
Required Provided Required Provided Required >videdcnrn
.00
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal SysUp:
Public 13 Private 13Zone: _ Outside Flood Zone?Check if yes❑ I Municipal E3On site disposaa system El
SECTION 2: PROPERTY OWNERSBIP'
2 e 'of Recor q 'f
i'r �� � ffk
NAV t) city,Sta
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ I Alteration( n ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2:
CI
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 6 J 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: $
6.Total Project Cost: $lb� fm(� _ Check No. Check Amount: Cash Amount:
❑Paid in Full ❑ Outstanding Balance Due:
mAt t C0 N-r- t,L/ z7
SECTIONS: CONSTRUCTION SERVICES
5.1 Constru tion Supe icense(CSL) S� y
,nn\\
, /7 WW License Number Expiration Date
N e of CSL Holder
roG '7 2?2�lJ�(1. %"�1_�J List CSL Type(see below)
No.and Street / Type Description
��,( 9A- ' dais U Unrestricted(Buildings u el 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
Ci /Town,State,ZIP M Masonry
RC -Rooling Covering
WS Window and Siding
) SF Solid Fuel Burning Appliances
I' a 7d0 1 IInsulation
Telephone Email address D Demolition
5.2 RegisteromiImpro ement Contractor(BIC) 1� 33L _ aLy
iqJx--1T-D Y1 HIC Registration Number Expiration Date
Com any ame or HIC R 'strant ame I
N id S( /S y/��6��I v� Email address
City/Town,/Town,State IP (1 Telephone
,"7UU�
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.1 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
I,as Owner of the subject property,hereby authorize
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: OWNEW OR AUTHORIZED AGENT DECLARATION
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 accurate to the best of my knowledge and understanding.
,lllu
PiInt Owner's or Autho ent's NamlecYonic Signature) Date
NOTES:
I. 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.pov/dps
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"