17 MESSERVY ST - BUILDING INSPECTION I� rhe Commonwealth ol'Massachusetts
Board of Building Regulations and Standards CITY
( Massachusetts State Building Code, 780 CMR, 7"edition OF SALEM
Board
IIWI Building Permit Application ro,Construct, Repair, Renovate Or Demolish a /. '008
One-or Two-Funril_v Dwelling
This Section For QBicial Use Only
Building Permit Number: Oalk Appl'ed:
Signature: t , �yl
Building Commissioner/Inspec of Buildings )'e
SECTION I:SITE 1176PMATION
1.1 Property Address: I. Assessors Map& Parcel Numbers
M P-S
I.I a Is this an accepte street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(tl)
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:
Zone: _ Outside Flood Zone?
Public O/ Private❑ Check ifyesO� Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of(tecord: `L� I tjotj)— �i 3AB
Name(Pri ) �J Address for Service: 1'
9119 " ITZ
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ 1 Existing Building❑ 1 Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': SX j ;,,,. t e. . f,,L.r
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1. Building S 1. Building Permit Fee:S Indicate how Ice is determined:
�. Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 1. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:$
4� Check No._Check Amount: Cash Amount:
6. Total Project Cost: S 3 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5,1 Licensede7
onstructionSupervisor(CSL) 1Or1 "sq 'b
, \b,w Okc:� License'Number lispiratio Date
Na a nl 'SI -I lot eV
Liu CSL Type(see below)
Address 1Gt—+ i [ �L'rL -fs' Description
D Unrestricted(tip to 35,000 Cu.Ft.)
It Restricted 1&2 Family Dwellin
Signature M \1asonry Only
RC Residential Roolin,Covering
I elephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.�egis�t`ere Home Im�verenI Contractor(HIC) s�t�� /
I11C Com ame or IIC It e tmn n Regis 'un Number
A4 Q^ A�j,"�'�O� /Z 3
! 7d L q Z,7K Expiration l5afe
Signature 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 ..........ErNo...........13
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.
Signature of Owner Date
DSECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I, � ,as Owner or Authorized Agent hereby declare
that the st e aan , ation on the foregoing application are true and accurate,to the best of my knowledge and
behalf. ,
Prim Name
Signature ofOwneror uthorized Agent Date
(Signed under the painsand penaltiesofperjury)
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(MIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the IIIC Program ani
Construction Supervisor Licensing(CSL)can be found in 730 CMR Regulations 110.116 and I I0.R5, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Ilabitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of hal0baths
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"