0013 GRISWOLD - BPA-15-1262 The Commonwealth of Massachusetts
Board of Building Regulations and Standards. CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mor 1011
Building Permit Application To Construct, Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
I Building Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
N 1.1p A(Idress: 1.2 Assessors Map&Parcel Numbers
I r �rl mol a�
` 1.1 a Is this an accepted street?yes no Map Number Parcel Number o z
1.3 Zoning Information: 1.4 Property Dimensions: z m
1i 1 0 `7
Ir Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) o m
1.5 Building Setbacks (ft) w y m
Front Yard Side Yards Rear Yard D cn r*t
Required Provided Required Provided Required Prided �
W C;i
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Ln
Public O Private O Zone: _ Outside Flood Zone? Municipal 13 On site disposal system O
Check ifyesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownerof RecoqAr�
0 iC e Y)"" ,1- O'c
Name(Pri IVCity,State,ZIP
j,P9.r)'s INddL
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction 0 Existing Building 13 Owner-Occupied O I Repairs(s) O I Alteration 'tion 0
Demolition O Accessory Bldg.O Number of Units I Other, 9 Specify:
Brief Description of Proposed Work 2:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ L6 6I)d 1. Building Permit Fee:$ Indicate how fee is determined:
O Standard City/Town Application Fee
2.Electrical $ O Total Project Cosh(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: $l(p D� O Paid in Full 13 Outstanding Balance Due:
MrAtt-x �A ( Zp
— - 1
SECTION 5: CONSTRUCTION SERVICES
5.1 ons on Supervlso L ease(CSL)
[ /S LJ
� l ' h)
l
a h ) ) License Number Expirati n Da(c
Naml of CSL Holder
V ' V— ^,,, , `k% J � List CSL Type(see below)
No.and Street ) /(/� l Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
V f I R Restricted 1&2 Family Dwelling
Ci /fo , a e,ZIP
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Tel hone Email address D Demolition
5.2 Registere#Tome I prov Contractor(HIC) 3 <�-/ _
IfflM Qn HIRegistration Number x tg onTiate
Company arae or Re M trent Nowe /L
IMr' I 1 d rU ei 6,I VA)_RD»l
Str � Email address
City/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...........17
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUELDING 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:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
con fined ' this application'is true and accurate to the best of my knowledge and understanding.
/ ffbh r' r
Pri t Owner's or Authorked Agent's Ndne(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(RIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A. Other important information on the RIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dpss
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"