24-26 GREEN - BUILDING INSPECTION 1 1
The Commonwealth of Massachusetts
>I ,t Board oC Building Regulations and Standards CITY
Massachusetts State Building Code, 730 CMR, 7"edition OF SALEM
Revived JanuarV
Building Permit Application To Construct,Repair, Renovate Or Demolish a 1. 1008
One-or Tno-Family Durellir
ThisS3: t For Official 0sc Only
Building Permit Num r. J J Rate plied:
Signature:
Building CommissioneW Inspector ofit 'ngs Date
SECT6N 1:SITE INFORMATION
1.1:rope %ddress r.��� 1.2 Assessors Map& Parcel Numbers
I.1a Is this an accepted street'?yes ono Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rea Yard
Required Provided Required Provided Required Provided
1.6 Water ly:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public Private 13Zone:
iryes&i Municipal Visite disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2. Ownersofl? cord: �4' ��rs� %j—
Gw. '1
Name int) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work'-:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I. Building g I. Building Permit Fee:S Indicate how Ice is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (MVAC) S List:
5. Mechanical (Fire S
Su ression Total All Fees: 5
Check No._Check Amount: Cash Amount:
6.Total Project Cost: S ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
Licensed sfraction Supervisor(CSL) ibfr/�(r-� % Ib r
License Number Exiluation Date
Name of Cul'C:Sl:I loider List CSL F)PC(see below)
`1
DescrI tion
:\JJres� I/ Unrestricted(tip to 35,000 Cu. Ft.)
It Restricted 16&2 Family Dwellin
Signuteury�pell, M �bhuun Only
�-rX ITI RC Residential Rtwfin Cuverin
I elephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
1) 1 Residential Demolition
5.2 Re istered no Improvement,ontractor(HIC) A�
ow,n (r III gygC' fo on Number
i IIC Comps am or HIC Registrant Nate Re�istra on NumM:r
AJJrcss ���
C.pimtion Date
Sig ature 'relephone
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 .......... Nu........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, , 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.
Signature of Owner Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
t
1, 1 as Owner or Authorized Agent hereby declare
that the statements and info anon on the foregoing application are true and accurate,to the best of my knowledge and
behalf. r
Print Nam
Signutum of Owner or ooze gent Dat
Si med under the sins and enaities of er'uly
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 110.116 and 110.115, respectively.
2. When substantial work is planned,provide the information below:
Total Iloors area(Sq. Ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(Sq. FL) Ilabitable 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'