B-19-163 - 0005 ALMEDA STREET - Building Permit :� CK 92-6
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 Official Use.Orily
—� Building Permit Number Date Applied:
-19
Building Official(Print Name) Signature Date
SECTION-1 SITE,INFORMATION
1.1 O=Wb#
ddress: 1.2 Assessors Map&Parcel Numbers
S
Lla 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?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2. PROPERTY.O.WNERSHIP'. .
2.1 wner�of Recor
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
"SECTION 3 DESCRIPTION OF PROPOSED WO]w(check all°that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work 2:__ �%/JS�/��,�,✓ Gy�tl(f.� ����s�
:SECTION ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1.Building $ 3 od f/� L. Building Permit Fee`.$ Indicate how fee is determined
Standard City/Town Application Fce " '
2.Electrical $
0 Total Project Cost.1. (Item 6)x multiplier x; r-
3.Plumbing $ 2 Other Feesdn
: :$
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total A11 Fees: $
Check No Check Amount Cash Amount
6. Total Project Cost: $ o j 7 ] El Paid in Full ❑Outstandmg:`.Balance Due.
20 t 3 M���p � C-orn r^ • �N
n
SECTION 5 CONSTRUCTION_SERVICES
5.1 Construction Supervisor License(CSL)
1 / �p y /off ll9
V ''dexy-r ���y/ �'� License Number Expiration Date
Name of CSL Holder
otPuy
t ' '/ 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 Siding
SF Solid Fuel Burning Appliances
l L���iN ('G1� /✓ 1 insulation
Telephone Email a dress D Demolition
5.2 Registered Home C Improvement �a Contractor(HIC) l -5-Y 7 Zp 9 o �o�wlr rN eAwy HIC Registration Number Expir tion Date
HIC Company Name or HIC Registrant Name
/�/,vL,i✓S(ua r �i v �✓i +r4r(��ur�Noy
No and Street Email address
6174W-VAv
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 BUIL.DING:PERMIT
I,as Owner of the subject property,hereby authorize V C vGEalr�Wpr,,�✓ ho"im6kAAf Py �1
to acton my behalf,in all matters relative to work authorized by this building permit application.
/� YJAti l) lZ /
Print Owner's Name(Electronic Signature) Date
SECTION 7bc.OWNEW OR AUTHORIZED AGENT DECLARATI.ON
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.
I 2-h Z-/1 I
Print Owner's or Authortzed 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.gov/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"