B-19-376 - 0010 ANDREW STREET - Building Permit I
Q�l The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY 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 Only ;
Building Permit Number: Date Applied:
5� of, CA77
Building Official(Print Name), Date-..
ION
SECTION-:1 SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes no Map Number Parcel Number V
1.3 Zoning Information: 1.4 Proper imensions:
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
^/A
1.6 Wafer Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Public EY; P ivate❑ — Check if yes❑ Municipal❑ On site disposal.system ❑
SECTION 2:.PROPERTYOWNERSHIP'
2 T of Record: -10
r N iint)N t City,State,ZIP
Nti-and Stre Telephone Email Address
SECTION 3•D.ESCRIPTION OF,PROPOSED WORK check.all that a 1 Gv
py ( PP Y),
New Cons rf�i ction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2: �ZrGPIACJE 03' A A ApQWA� �\V��
SAME mc_v
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ �O�,S 1" Building Permit Fee .$ Indicate h6v fee's determined:
11 Standard City/Town Application Fee ,
2.Electrical $ ❑Total Project Cost'
(Item 6)x multiplier- � x
3.Plumbing $ 2: ,Other Fees: $
4.Mechanical (HVAC) $ List
5.Mechanical (Fire $
Suppression) Total All Fees: $
Che No.' Check mount: Cash Amount: "
6.Total Project Cost: $ -7 \C% paid in Full ❑Outstanding Balance Due:
4 Iv, VA A t L s�1p Tb G.C-. C�A*
i
SECTION 5f'CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration f5ate
Name of CSL Holder
List CSL Type(see below)
No.and Street T e,: Description
w a A Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
'� '.���3��� �.1�`it�l,��,,[.�AL.•C.D I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor-(HIC)
L� •/lam 1 � 0 og ooa \o C./go
c�►sTGo HIC Registration Number Expiration Date
HIC Company Aame or HIC Registrant Name
No.and Street Email address
!HENS ch li
i ta o�q�8�►$3�'1 3`t�3
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 Issuanc of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION lac 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.
2-
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.
Print Owner's or AuthorizedAgent's Name(Electronic Signature) Date
NOTES:.
1. An Owner who obtains a building permitIo 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. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dpss
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/batbs
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
r3. "Total Project Square Footage"may be substituted for"Total Project Cost"