0001 GRISWOLD DRIVE - BPA-15-1260 r
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The Commonwealth of Massachusetts
WBoard of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
kJ 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:
�l-Y(w�,r>l II 13 If
Building Official(Print Name) Signature QU Date
i SECTION 1:SITE INFORMATION
1�1 P erty Addre�s: 1.2 Assessors Map&Parcel Numbers
r) S W7�0
1.1 a Is this an accepted street?yes no -Map Number Parcel Number
Ln
13 Zoning Information: 1.4 Property Dimensions: ,C= m
z c-)
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) Z_
1.5 Building Setbacks(ft) w grn
Front Yard Side Yards Rear Yard r
Nm
Required Provided Required Provided Required ided M
W"
c=2
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal Systffi:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check ifyes❑
SECTION 2: PROPERTY OWNERSHIP'
O t of Recor
Lyjp � 1'h
a7rpe t) V City,State,ZIP
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) ❑ Altemtion(s dition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work-2: t L,in, L
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $/,p 1. Building Permit Fee:$ 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: $
/ l Check No. Check Amount: Cash Amount:
6.Total Project Cost: $/l0, �v ❑Paid in Full ❑Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 CoTsedon Supervis icense(CSL)npf 0o License Number �lY Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
D {�1/�/. /q�/ U Unrestricted(Buildingsu to 35,000 cu.ft.
x' - //� R Restricted 1&2 Family Dwelling
Ci /Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF I Solid Fuel Burning Appliances
S J I Insulation
Telephone Email address D Demolition
5.2 Registered f me Im roveme t Contractor(HIC)
u � HIC Registration Number Expiration Date
om an ��or e ¢ t N 'I egist ati
No. Stree /+ G't/�/ �l[J'I�IfC.�'i r' "/•�.d'�/
hrd 2A
/ v—3 d s Email address
Ci /Town State Z 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.......CPLI
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: OWNERS 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 appficattoKi i true and accurate to the best of my knowledge and understanding.
GM)kWitt
Print Owner's or Authorized Ag tis N#ne(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. og v/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"