8 ORNE SQ - BUILDING INSPECTION CK OQIT,7-
ILK The Commonwealth of Massachusetts
W
Board of Building Regulations and Standards CITY 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 plied:
a -7//
Building Official(Print Name) - Signature Date
_ SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel umbers
9 ORAIF &U
(� 1.1 a is this an accepted street?yes_ no Map Number Parcel Number
1.3� ing Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if yes0 Municipal❑ On site disposal system ❑
,. SECTION 2: PROPERTY OWNERSHIP'
2.1 OV#eri of R
Name(Print) I City, tate,ZIP
g orwp. mum gV" (4 60TACAECAOL.coy
No.and Street Telephone Email Address
m� SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description ofProposed Work : rr A-a otr
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 'kOfficial Use Only.
Labor and Materials). ...
1.Building $ , t)p -1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee_ r A :a
2.Electrical $ 6q '1 00. t)0 ,❑Total Project Cost'(Item 6)x multiplier x .
3.Plumbing $ 1P-0 OD 2. Other Fees:;$
4.Mechanical (HVAC) $ List: - - -
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: § Cash Amount: '
6. Total Project Cost: $
qo 11 Paid in Full a,. ❑Outstanding Balance Due:
1 V C--0 -N-ID C-ID N i 1`12I I (a
SECTION 5: C NSTRUCTION SERVICES P
5.1 Construction Supervisor License(CSL)
�C, v.0 r�t(L License Number Expiration Date
Name of CSL Holder
5 rl R n , �y�J t �� �� List CSL Type(see below)
No.and Street Type Description
Unrestricted uildin s up to 35,000 cu.ft.
v 1 Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
,p SF Solid Fuel Burning Appliances
�Q0 L ne &seSg . r I Insulation
Telephone Erma�il address _N e,-!d D Demolition
5.2 Registered Home Improvement Contractor(HIC) _
c e�hpcA Q�,y�.e2 t �4 r1
HIC Compan N or C Registrant Name HIC Registration Number Expiration Date
,• eL-Jsl m J !1, t %� mp Ak.V: Lu.L Lees®Eca-tCA0—
No.and StLket Email address rI`+'el
t 1'3
Ci /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...........❑
.. SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN_T „
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize J C�rr I uKN L�
to act on my behalf,in all matters a tive to wor authorized by this building permit application.
Print Owner's Name(Electronic Sig e) Date
` SECTION 7b:OW Rt 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 its true and accurate to the best of my knowledge and understanding.
Print Owner's or Author d Agent's Name(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.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/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"
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21 DARTMOUTH STREET DATE
SOMERVILLE MA 02145 �� (2—T 19