B-17-286 - 0002 ALBA AVENUE - Building Permit ti N ti:.
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y` The Commonwealth of Massachus6ft''ds q; P L j jl, { s
Board of Building Regulations and Standar CITY Massachusetts State Building Code,780 APR 19 A 9- gQ SALEM
,
tsed Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Onl ;k
NBudmg Permit Nu[iber Date lied
Building Ofcial(Print Name) Signature s Date
SECTION"1 Si .
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
2 � ,41J4,
1.1 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 ft) Frontage(ft) y
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❑ On site disposal system ❑
Check if yes❑
SECTION 2: 'PROPERTY OWNERSIIIPI
2.1 Owner'of Record:
Name(Print) y City,State,ZIP
�, �a 19�/E Sates Y9�-oCa�
No.and Street Telephone Email Address
SECTION 3:DESCRIP.TION OF PROPOSED WORK (check all that apply),
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) g I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work 2: G
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item O:fAcial Use OinIy
Labor and Materials - x
1.Building $ 00 1. Building Penmit Fee $x z Inchoate how fee i"s determined:
2.Electrical $ ❑Standard'City/Town App teat. Fee
❑Totai`Prolect Costa(Rein 6)x nultipher x
3.Plumbing $ 2 'Other Fees,
4.Mechanical (HVAC) $
List;.
5.Mechanical (Fire $ Total All Fees.$
Suppression)
Check No. Check A>nount' Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance D.ue
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name ofCSL Holder
List CSL'fype(see below)
QfJI
1 Type Description .
No.and Street
U Unrestricted•(Buildings Uji to 35,000 cu. tt.
R. Restricted 1&2 ily Dwelling
Cityfrown,State,ZIP M Masonry
qW Roorinit Coverin
WV Window and Siding
SF Solid Fuel Burning Appliances
? N-j—a` ��_,�517! 1 Insulation
Telephone Email address I D I Demolition
5.2 Registered home Improvement Contractor(HIC) /6161/ — /7
�B.h t-k#"a HIC Registration Number Expiration Date
C�mpan�y Nam o HI R,gistrant Name
No.and Street /� Email address
✓tr 1 - y ��r/-�yy-fsff2
Cityfrown,StateZIP Telephone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M:G,L..c.152.
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Is§uance of the building permit.
Signed Affidavit Attached? Yes..........❑ No...........0
SECTION 7a:OWNER AUTHOMATION TO BE.COMPLETED.WHEN:'
OWNER'S AGENT OR CONTRA:&6.It APPLIES:FOIL BUILDING.PERMIT
1,as Owner of the subject property,hereby authorize ,/ /G ✓� �P Ntt•YI S ` -
t9 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 6ndei the pains and penalties.of perjury that all of the information
contained in this applic 'on is true and accurate to the best of my knowledge and understanding.
� V f/7
Print Owner's or Authorize)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 nut'.have access to the arbitration
program or guaranty fund under NI.G.L.c. 1 d2A.Other important information on the HIC Program can be found at
xtiww.mass.eovloca Information on the Construction Supervisor License can be found at www.mass.gov'dus
2. When substantial work is planned,provide the information below:
"total floor area(sq. ft.) N ,(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
). "Total Project Square Footage"may be substituted for"Tutal Project Cost"