B-17-544 - 0008 ALBION STREET - Building Permit 2-)r. b
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
^ _ Tits Section For Official LTse Onl
U ) ,
Building Permit Dumber Date A laed s
Building Official(Pi mt Name) Signature y Date
_ SECTION 1` SITE INFORMATION, , , ,y ; .'
1 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
$ AGB/6 A, S.-
L la 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)
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 0",ERSHIP'
2.1 Owner'of Record:
,ELIZA SAIJTO S '519a M. /Y A 0/2 7 O
Name(Print) City,State,ZIP
8 ALAIPA) sT
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED.WORK (check all that apply):
New Construction❑ Existing Building R( Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other 11(Specify:WiA'T1ifk1Z#T 6-A1
Brief Description of Proposed Work2:
INS ULATE ATTIC 4- fX:aA1QR AWIS USING 134OU241 (',A-LLU&QSE
SECTION 4t ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Labor and Materials) Official Use Only
1.Building $ 3 D0 °° -1 Bull diig Permit Fee $ Indicate how fee is determined:;
2.Electrical $ U Standard CityaT owti Application Fee
y,: s
Q Total Project Costa(Item 5)x rriultiplier x :
3.Plumbing $ 2 Other'Fees
4.Mechanical (HVAC) $ List
5.Mechanical (Fire
Su $ Total All Fees:
ression
oa Check No . . Cheek Amount: Cash Amount:
6.Total Project Cost: $ 406. b Paid in Full 0 Outstanding Balance Due
fAl L I U C-L-S A �S
s
M 1-\i L-i=� vI -ZZ-
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SECTION 5: CONSTRUCTION SERVICES +
5.l Construction Supervisor License(CSL) CS"!Dlg 7.:i
� � License Number Expiation Date
Nang ofCSL Holder
r List CSL'rype(see below) U
�J a Type, ,. Description ..
No.eind Street
U Unrestricted(Buildings a to 35,000 cu. 11.
R Restricted 1&2 Family Dwelling
City(rown,State,ZIP M Masonry
RC Roo tin Covering
WS Window and Siding
/ p SF Solid Fuel Burning Appliances
I Insulation
—Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) /LO A3-dS
6_`T1r, A C6N7MC TiA)CY C_D . HIC Registration Number Expiration Date
I IIC Company Name or HIC Registrant Name
2-2 t0#5WJA167_0AI S T
No.and LStreet o� Email address
City/Town State,ZIP Telephone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M:G,L.c.152.12$C(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 Is§uance of the building permit.
Signed Affidavit Attached? Yes.......... No...........O
SECTION 7a.OWNER AUTHORIZATION TO BE.COMPLETED.WHEN:
OWNER'S AGENT OR CONTRACTOR APPLIES:FOR BUILDING.PERNIIT
1,as Owner of the subject property,hereby authorize c�i GCCA �'.UNTIe/9C%7rG/V6 C O o -
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print 0 er's Name(Electronic Signature) Date
SECTION 7b:6WNERt ORAUTHORIZED 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( wner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to Jo 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. 142A.Other important information on the HIC Program can be found at
xvwvv.mass.eow!oczt Information on the Construction Supervisor License can be found at www.mass.gov!lm .
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. "rotal Project Square Footage"may be substituted for"Total Project Cost"