0009 VISTA AVE - BUILDING INSPECTION (003) ., � j• U • no
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Building Permit Application To Construct,Repair, Renovate Or Demolish a ReWsedMar 2011
One-or Two-Family Dwelling
` '4 This Section For Official Use Only
Building Permit Numbed Date Appl'ML
,a.
Building Official(Print Name) .Si .lure
' ate +, -.
-1.1 Propr : r SECTION 1:SITE INFORMATION
V ddress: OV"_ 1.2 Assessors Map&Parcel Numbers
I.In Is this an accepted street?yes_ no_ Map Number -Parcel Number
1.
3 Zoning
Information. 1.4 Property Dimensions:
Zoning District Proposed Use Lot Areas
( q fl) Frontage(ft)
1.5 Building Setbacks tit)
Front Yard Side Yards
Required Provided Required Provided
Required Rear YardProvided
1.6 Wate Supply:(M.G.L c.4Q §54) 1.7 Flood Zone Information: 1.8 Sewage Dispos al System:
11
Public Private El Zone: _ Outside Flood Zone?
Check if yes[] Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of ecord: " "s
i1-fl P.tt%✓i4264 U 1*� _ �S/1 Lc/+� /Lt A Name(Print)
V1_AQ A-1 Cry,State,ZIP
No.and
Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORNZ(check all that apply)
New Constmction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s)-❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units
her ❑ Specify:
Brief Description of Proposed WorkZ: �
f / `
KZ
2 SECTION A:ESTIbIATEp CONSTRUCTION COSTS
Item . Estimated Costs.
Official Use Only
1.Building $ L Building Permit Fee: $ Indicate how fee is determined G
2.Electrical $ ❑Standard City/Town Application Fee
O . OU 3. Plumbing $ ❑Total Project Costa(item 6)x multiplier . ""_ ' x
2°' Other Fees: $
4.Mechanical (HVAC) $ List.
5.Mechanical (Fire
Su ression $ Total All Fees: $
Check No. Check Amount r e
6. Total Project Cost: $ Cash Amount.
`� OOa. D ❑Paid m Full'` ❑Outstanding Balance Due.
' SECTION 5: CONSTRUC4IDemolifion
CES ;'
5.1 Construction Supervisor License(CSL)
ber Expiration Date
Name of CSL Holder
e(see below)
No.and Street ` ,, DescnpaonUnrestricted(Buildin s u to 35,000 cu.ILCity/Town,State,ZIP Restricted I&2 Famit Dwelius000fm Covindow and Sidolid Fuel Burning Appliances
nsulationTele hone Emaildress emolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name RIC Registration Number Expiration Date
No.and Street
Email address
City/Town,State,ZIP Tel hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT iM.G.Jftilde,
Workers Compensation Insurance affidavit must be completed and submitted with this applicvide
this affidavit will result in the denial of the Issuan of the building permit.
Signed Affidavit Attached? Yes.......... No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN ,OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDINGP1,as Owner of the subject property,hereby authorize "--9-a-4 b Lop
to act on my behalf,in all matters relative to work authorizeedd by this building permi pplicatiAA L�l 'Font Owners Name(Electronic Signature)
,SECTION 7b: OWNERt 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
., s. ., 8 "
NOTES:
1. An Owner who obtains a building pemtit 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 MG.L. c. 142A. Other important information on the HIC Program can be found at
www.mass.mov/oca Information on the Construction Supervisor License can be found at www mass gov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) u ooe.00 (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ,6t7.356 dp Habitable room count
Number of fireplaces 1 Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system utQa�h's 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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