B-17-704 - 0013 APPLETON STREET - Building Permit r c t< l O t-`�
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
O
Massachusetts State Building Code, 780 CMR SALEM
S Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
n One-or Two Family Dwelling
�•.J This Section For Octal LTse Onl
Biuldmg Pernirt Number Date plied 4
Budding Official(Print Name) Signature Da
tr
SECTION SITE INFORMATION,z
1 , N
oz
1.1 Property Address. / 1.2 Assessors Map&Parcel Numbers a y
1.1a Is this an a cepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: vu ,
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yazd
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- OVVNERSHIPi r
2.1 Owner'of ReFord:
Name(Print) City,Stat Z
No.and Street Telephone Email Address
SECTION 3 DESCRIPTIOIN OF PROPOSED ORK?(check a bat:apply) ;
New Construction❑ Existing Building Owner-Occupied 21Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units - Other ❑ Specify:
Brief Description of Proposed Work2:
SECTION 4:ESTIMATED CONSTRUCTZON COSTS
Estimated Costs:
Item QtI-ictal Use Only
Labor and Materials
1.Building $ N -- `'1 Builduig I'ertit Pee $ Indicate how fee is determined;
2.Electrical $ Standard�Crty(Town Applicatton Fee
p Total Prote Jer x
3.Plumbing $ 2 Other Fees:`$
4.Mechanical (HVAC) $ List,,
5.Mechanical (Fire
Su ression $ Total Ali Fees:$
Check No. Check Amounts Cash Amount::.
6. Total Project Cost: $
❑Paid in Full O Outstanding Balance;Due.
S
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) �� j`15
Jz ������ License Number Expiration Da O
Name ofCSL Holder
&4 � List CSL'fype(see below) .
1
Type, . . Description ..
No.and Stre It .
Unrestricted(Buildings L 10 to 35,000 cu. 11.
(/ R' Restricted 1&2 Family Dwelling-
Citylfown,State,ZIP �It Masonry
RC Rooting Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
e-7 f J 'f --/ s y33 � w I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) /5-/' .7
v HIC Registration-Number xpiru on Date
IIIC Compan a or C Re ' trant Name 3 i
y Emai ddress
71� f 7/
City/Town, State IP Telephone
SECTION 6:WORKERS'.COINPENSATION INSURANCE AFFIDAVIT(M.G;t::.c.152.§25C(6)Y..
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...........13
SECTION 7a.OWNER AUTHORNUTIONTO BE.COMPLETED.WHEN:
OWNER'S AGENT OR CONTRACTORtA/P'PLIES'FOIt BUILDING.PBRd1IT
1,as Owner of the subject property,hereby authorize / v U d.4 4N" -
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Dat
SECTION 7b:OWNERt OR AUTHORIZED AGENT DECLARATION
By entering my name bel w,I hereby attest under the pains and penalties of perjury that all of the information
contained in this applica s true and accurate to the best of my know) dge and understanding.
Print Owner's or Authori d 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. I42A.Other important information on the HIC Program can be found at
xvw%v.mass.gov!oca Information on the Construction Supervisor License can be found at www.mass.,ov!dL .
2. When substantial work is planned,provide the information below:
'total fluor area(sq. R.) ,(including garage,finished basement/attics,decks or porch)
Gross living area(sq. tt.) 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"