_BUILDING JACKET 0
The Commonwealth of Massachusetts
Board of Building Regulations and Standards' Town of
Massachusetts State Building Code, 780 CMR, 7"edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a It
_ One- or Two-Family Dwelling
�)\ This Section For Official Use Only
Building Permit Numb Date Applied:
Signature::.
Building CommissionerVinspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Prope Address: 1.2 Assessors Map& Parcel Numbers
L l a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) 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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
,1r--Owner'of Rgy�'grd:
� T`ONfi{'.�
Name(Print) Address for Service:
-Z, 97 0 7Y'5 -7 7(1i
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) 06 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of P gosed Work2:
Ke place FAA rvr-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 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. Plumhinp $ 7 Other Fees: $ _ �^
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ 'Total All Fees: $
r6Supprcssion
Check No. Check Amount: Cash Amount:
Total Project Cost: $ dn Sp0-r''O ❑Paid in Full ❑Outstanding Balance Due:
�'l�i� �v' Rf��ye OC✓.aPl�
.f
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
"'. . . License Number Expiration Date
N,4mc of CSL-Helder List CSL Type(see below)
L i T Description
Address U Unrestricted(u to 35,000 Cu. Ft.)
R Restricted 1&2 Famil Dwellin
Signature M Mason Only
RC Residential RoofingCovering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Dale
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 .......... ❑ .No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S GENT OR RACTOR 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
1, ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury
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 1 I O.R6 and I IO.RS, 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.) 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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\� The Commonwealth of Massachusetts
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 Oal Use Only
Building Permit Number: DIle Applied:
-t�o
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION -
1.1 Property Addres 1.2 Assessors Map&Parcel Numbers
Lla Is this an accepted street?yes__-_,L no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) 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? Municipal B"On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Edv--crrd N,4 �) r . Sa rX,%1) 0�9r) D
Name(Print) City,State,ZIP
.-.a t clz,,O '- nl A5 n tl lol
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORICZ(check all that apply)
New Construction❑ Existing Building '71Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work 2:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ Z 3 t]t> 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(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: $ 2'.CND 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1—rC—onstruction Supervisor License(CSL)
�— )—A V��\f� License Number Expiration Date( /
Name of CSL Holder S
\ O C' n��\ List CSL Type(see below) �.IJ
No.and Street l� Type Description
c)1�S 1..4 a U Unrestricted(Buildings u to 35,000 cu.ft.)
R Restricted 1&2 Family Dwellin
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
q����,� ��l SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) �[ /6
SaA4--N4- l4i L paff-E9kiorr HIC Regist ZK
ration tion Number Expi atm Date
HIC Company N to or HIC egistr tNarkt
n
L C>rll�
No.and Str t t. o(ra A Z���fy Email address
City/Town[
i /To/Towwnn, State,ZIP dt0et--Telephone I
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: OWNFAR 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: 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
contained in this application is true and accurate to the best of my knowledge and understanding.
.3- a s'I3
Print Owner's or Auth rized Agents Name.(Electronic Signature) fDate
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.gov/oca Information on the Construction Supervisor License can be found at www.mass.uov/dos
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"maybe substituted for"Total Project Cost"
L4 .7
c K. 2Fs 3�(
�7 The Commonwealth of Massachusetts "VT10 AL SERVICES
al (w Board of Building Regulations and Standards 3
I SALEM A
V . ' „ Massachusetts State Building Code, 780 CMR Revised 22 �to
I 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 A ' d:
yJl "J--
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 2' 1 (�L 1.2 Assessors Map&Parcel Numbers
L I a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) 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❑ 'hone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check ifyes❑
SECT N 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:Todd On II ET—t Salem, MA. 01970
Name(Print) 21 bow st. - -
Djtodd2168@hotmail.com
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) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': } ,n
Q
S IM
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
I.Building $ 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:$
' r, Check No. Check Amount: Cash Amount:_
6.Total Project Cost: $ (/ 0 Paid in Full 13 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
JckmP S 1¢S1' i(r-�r—) License Number F.xpiraliunS DlallQe
Name of CSL Holder
1 p F✓'P 1( .VY _N`e A List CSL Type(see below) U
No.and Street 1 � Q, [ Type Description
O .� L �.A , r p Inu� �`�'tU U Unrestricted(Buildin s u to 35,000 cu.ft.
City/Towq State,Zf/lN✓ 1 R Restricted 1&2 Family Dwelling
M Masonry
RC RoofluR Covering
WS Window and Siding
�aSU��v\vi SF Solid Fuel Burning Appliances
1(}}C(j\((y t Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) "���
V V 1 l� � r HIC Registration Number Expiration Date
HIC Co Tl gy;N�n�r i,.[ IC,Regist(ant Name
No.an 'treet u vj(,`�Jg" `y 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...........❑
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 ' Ay\n t SU\CIY
to act on my behalf,in all matters relative to work authorized by this building permit application.
Zb,//� 0 04/02/15
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
contained in this application is true and accurate to the best of my knowledge and understanding.
6---K4� � ,� �
Print Owner's or Authorized Agent' a(Elec nic Signature) Da[
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(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.gov.foca 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"
Y gyp.. �}
f ICI 0 u ryr,�Il Ile solar 3301 North Thanksgiving Way, Suite 500
Structural Group Lehi, LIT 84043
P: (801)234-7050
Scott E. Wyssling, PE
Head of Structural Engineering scott.wyssling@vivintsolar.com
April 2, 2015
Mr. Dan Rock, Project Manager
Vivint Solar
24 Normac Road
Woburn MA 01801
Re: Structural Engineering Services
Oneil Residence
21 Bow St, Salem MA
S-4199402
4.25 kW System
Dear Mr. Rock:
Pursuant to your request, we have reviewed the following information regarding solar panel installation on the roof
of the above referenced home:
1. Site Visit/Verification Form prepared by a Vivint Solar representative identifying specific site
information including size and spacing of rafters for the existing roof structure.
2. Design drawings of the proposed system including a site plan, roof plan and connection details for
the solar panels. This information was prepared by the Design Group and will be utilized for
approval and construction of the proposed system.
3. Photovoltaic Rooftop Solar System Permit Submittal identifying design parameters for the solar
system.
4. Photographs of the interior and exterior of the roof system identifying existing structural members
and their conditions.
Based on the above information we have evaluated the structural capacity of the existing roof system to support
the additional loads imposed by the solar panels and have the following comments related to our review and
evaluation:
Description of Residence:
The existing residence is typical wood framing construction with the roof system consisting of 2x6 dimensional
lumber at 29" on center. The attic space is unfinished and the photos indicate that there was free access to
visually inspect the size and condition of the roof rafters. All wood material utilized for the roof system is assumed
to be Spruce-Pine-Fir #2 or better with standard construction components. Our review of the photos of the
exterior roof does not indicate any signs of settlement or misalignment caused by overstressed underlying
members.
Stability Evaluation:
A. Wind Uplift Loading
1. Refer to attached Ecolibrium Solar calculations sheet for ASCE/SEI 7-10 Minimum Design Loads
for Buildings and other Structures, wind speed of 100 mph based on Exposure Category"B" and
40 degree roof slopes on the dwelling areas. Ground snow load is 40 PSF for Exposure "B", Zone
2 per (ASCE/SEI 7-10).
2. Total area subject to wind uplift is calculated for the Interior, Edge and Corner Zones of the
dwelling.
daeont. solar
Page 2 of 2
B. Loading Criteria
10 PSF= Dead Load roofing/framing 40 PSF= Live Load (ground snow load)
5 PSF= Dead Load solar panels/mounting hardware
Total Dead Load=15 PSF
The above values are within acceptable limits of recognized industry standards for similar structures and in
accordance with the 2009 International Residential Code. Analysis performed of the existing roof structure utilizing
the above loading criteria indicates that the existing rafters will support the additional panel loading without
damage, if installed correctly.
C. Roof Structure Capacity
1. The photographs provided of the attic space and roof rafters show that the framing is in good
condition with no visible signs of damage caused by prior overstressing.
D. Solar Panel Anchorage
1. The solar panels shall be mounted in accordance with the most recent "Ecolibrium Solar
Installation Manual', which can be found on the Ecolibrium Solar website (ecolibriumsolar.com). If
during solar panel installation, the roof framing members appear unstable or deflect non-
uniformly, our office should be notified before proceeding with the installation.
2. The solar panels are 1 Yz'thick and mounted 4 Yi'off the roof for a total height off the existing roof
of 6". At no time will the panels be mounted higher that 6"above the existing plane of the roof.
3. Maximum allowable pullout per lag screw is 235 Ibs/inch of penetration as identified in the
National Design Standards (NDS) of timber construction specifications for Hem-Fir (North
Lumber) assumed. Based on our evaluation, the pullout value, utilizing a penetration depth of 2
1/2", is less than the maximum allowable per connection and therefore is adequate. Based on the
variable factors for the existing roof framing and installation tolerances, using a thread depth of 2
I/Y with a minimum size of 5/16" lag screw per attachment point for panel anchor mounts will be
adequate with a sufficient factor of safety.
4. Considering the roof slopes, the size, spacing, condition of roof, the panel supports shall be
placed at and attached to no greater than every other roof rafter as panels are installed
perpendicular across rafters and no greater than the panel length when installed parallel to the
rafters (portrait). No panel supports spacing shall be greater than two (2) rafter spaces or 58" o/c,
whichever is less.
5. Panel supports connections shall be staggered to distribute load to adjacent rafters.
Based on the above evaluation, with appropriate panel anchors being utilized the roof system will adequately support
the additional loading imposed by the solar panels. This evaluation is in conformance with the 2009 International
Residential Code, current industry standards and practice, and based on information supplied to us at the time of
this report.
Should you have any questions regarding the above or if you require further information do not hesitate to contact me.
fsT
Ve ruly yours, _��" e °yam
Y I -
CIVI m
Scott E.Wyssli PE ° 50
MA License No.505 9�FESSIONA P�
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`/ q �m ROOF m m INSTALLER NUMBER:1.8774044129 21 Bow St
Py L,O p� MALICENSE:MAHIC170848 �pvo� . soar Salem,MA 01970
PLAN I DRAWN BY:KH I AR 41991 Last Modified:4112015 UTILITY ACCOUNT NUMBER:5067&12024
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The Commonwealth ofMassachusetts .
Board of Building Regulations and Standards FOR
Massachusetts State Building Code,780 CMR MUNICIPALITY
USE
Building Permit Application To Construct,Repair,Renovate Or Demolish a RevisedMar2011
L� One-or Two-Family Dwelling
This Section For Official Use Only
Building PemitNumber Date Applied:
Budding Official(Print Name) Signature
Date
SECTION 1:SITE INFORMATION
1.1 Propert3�ddress:�� 1.2 Assessors Map&Parcel Numbers
1.1a is ibis an accepted street?yes no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
` sa:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard - . .SideYm*
Rear Yard o
Required Provided Requued Provided Required Provided'
O
1.6 Water Supply:(M GZ a 40,§54) 1,7 Flood Z9Ae Information; 1.3 Sewage Disposal System: t Z rn
Public❑ Private El . .Zone: _ Outside Flood Zone? - J r
Checkifyes❑ Municipal❑ On site disposal system ❑ �rn
0
SECTION2: PROPERTY OWNERSHIP n
2.1 Owne of Record: 4
LZ'Nt cn m
Name(Prin - - Uty,State,Z� "� cn
421 lilt/ �f . 7 • `T2- �� r
No.and Sheet 'Telephone EmoilAddress
SECTION 3:DESCRIPTION OF PROPOSED WORK?(check all that apply)
New Construction❑ Existing Building❑ I Owner-Occupied ❑ Repairs(s) ❑ tetation(s) ❑ Addition ❑
Demolition'. ❑ Accessory Bldg.❑ NumberofUnits - Other Urspecify
BriefDescription ofProposed Work2:
IIS ,5
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated
Costs-
abor and Materials Official Use Only
1.Building $ 3 t ., 1,.Building Permit Fee:$ Indicate how fee is determined:
I Electrical $ ❑Standard. City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. OtherFees: $
4.Mechanical (HVAC) .$ List:
5.Mechanical (Fire
Su ression) $ Total All Fees:$
6.Total Project Cost: $3&W .> Check No.t 14 Check Amount: Cash Amount
❑Paid in Full ❑Outstanding Balance Duey'
SECTION 5: CONSTRUCTION SERVICES
&I Construction Supervisor Uceose(CSL) , IV gr-7-7
! .. LicemeNumber ftirstionDate
Name ofCSLHolder list CSLType(see below) uft.,
Eric W.Talm .
Street Type Description
nr No.andSh 3 Hilton
Street . `. U Unrestricted to3500D ca.1t.
r Salem MA 01970: " R Restricted1&2 Family Dwelling
city/rown,State,ZIP :,j;: .. M -
_ - RC Roofm Coverio
GG I Solid Fuel
�/�A� / ry WS WrmdowaadSiding
/1f�f , b.�� � IF. . Insulation BurningAPPliences;"
Tel hone Email adik s D I Demolition
5.2 Registered Home Improvement Contractor(HIC) oC O S Z �P
Atlantic WeadieriLatwiy 1,,.-. g�e h�on�N�6�er vationDate
MCCompaayNameorM7 Venue MC
Exp
e:.r MA nin7A , . .
No.and Sheet Email address
city/fowl). State,ZIP i Telyhone,
SECTION6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(1VLG.L r.152.§25C(6))
Workeas Compensation Insurance affidavit must be completed and submitted with this application.Failure to provide
this affidavit will result in the denial ofthe issue nce buddingpemtiL
Signed AffidavitAttachedl Yes.......... j No.........::0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTORAPPLIES FOR/BUH DING PERMTr
1,as Owner ofthe sabjectproperly,hereby authorize f rG �Cll f�'L
to act on my behalf;in all matters relative to work authorized by this building permit application. .
r J
Print Owner's Name Mechowc Signature) j Date
SECTION 76EOWNEWORAUTHORIZEDAGENTDECLARATION . '
By entaingmy name below,I hereby attest under the pains and penalties ofperjuty that all ofthe information
contained in apphca n is accurate to the best ofary knowledge and understanding.
PnotOwneesor Authorized Agent's Name.(Electronic Signature) J. Date -
NOTES:
1. An Owner who able*abuilding permit to do his/her ownwork,or an owner who hires an unregistered contractor
(notregistered in the Home Improvement Contractor(H[C)ftgmnX will norhave access to the arbitration
program or guaranty fund under M.G.L.c.142A.Other important information on the MC Program can be found at
www:mass.eov/ocaInformationon the Construction SupervisorLicense can be found atwww.mass.eov/dos '
2. When substantial work is planned;provide the information below:
Total floor aces(sq.&.) i t (including garage,finished basement/attics,decks or porch)
Gross living area(sq.it.) :, Habitable room count
Number offreplages Number of bedrooms
Number-ofbathmoms Number-of-half/baths
Type of heating system Number ofdecks/porches
_ Type of cooling system Enclosed Open
3. `Total Project Square Footage"maybe substituted for"Total Project Cose'.
C� 5(1
P l3- Itf - 13 2.
�. The Commonwealth of Massachusetts RECEIVED
Ulf
Board of Building Regulations and StandPECTIDNAL SE VICHSTY OF
Massachusetts State Building Code,780 CMR SALEM
��11tt �,11'�gg !�n�1 AA e+p d Mar 2011
Building Permit Application To Construct,Repair,Renova#Ur.'1'&Yn?Ah 4' J
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: FDate ph d:
Building Official(Print Name) Signature Dat
SECTION 1:SITE INFORMATION
1.1 PZyerty drr s: 54� 1.2 Assessors Map&Parcel Numbers
L I a Is this an accepted street?yeses no Map Number Parcel Number
1.3 oning 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 yes❑ Municipal IN On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of rd:
Edw+r f
, 0�27 b
Name(Print) 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 ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other Specify:
Brief Descriptjon g roposed Work :
r p p MgJ a�
V '13 rraa
C
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
abor and Materials Official Use Only
1.Building $ 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:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: ❑Paid in Full ❑ Outstanding Balance Due:
(�) vLZ ro M,L-
U Ali Es T13 M •I
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street
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
f 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
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: OWNEW 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 is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.&ovidps -
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"
• � J