B-17-650 - 0067 AURORA LANE - Building Permit .l C_
The Commonwealth of Massachusetts` 1
Board of Building Regulations and Standards ,t: CITY Massachusetts State Building Code,780 RJL 1 SALEM
I- Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
r, This Section For"Official Use Only
t Build ng;Permit Number: Date A hed. --
'Aev�
Building Official(Print Name) . Signature _ ._ Date:
SECTION 1:SITE INFORMATION = -
1 PropertX Address: 0 1 O Q o 1.2 Assessors Map&Parcel Numbers
L 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)
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 OWNERSHIP-1-_'_ w
2.1 Ownerl of Re d:
Name(Prin City,State,ZIP
6`1 ,nl.' �Aw e- S E51 46r ear 57f' k-al
No.a dtreet Telephone Email Address
SECTION 3s.DESCRIPTION OF-PROPOSED WORK, (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2: Y' "Pm
I
SECTION:4:.ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official.Use-Only
Labor and M terials
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ?00 s
❑Total Project Cost" (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ 'Total All Fees:$
Suppression)
N . Check
Check o C ec Amount: a h Amount•
S C Cs
6.Total Project Cost: $ `� ❑Paid in Full, ❑Outstanding Balance Due
Cam, L't- LA
'1
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SECTION 5: CONSTRUCTION SERVICES_
5.1 Construction Supervisor License(CSL)
L�e, CAM g�d cense Number Exfir'a—tidn Date
Name of CSL Holder
List CSL Type(see below)
No.and Street T e.' Description ,
U Unrestricted Buildin s up to 35,000 cu.ft.)
Restricted 1&2 Family Dwellin
. ' City ,State,ZIP M Masonry
RC Roofing Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
�._5q 3 66.3(o C�yCB• T/ Q� I Insulation
Telephone Email address a &OM D Demolition 5.2 Registerred_H�ome I�m/proive ent Contractor IC) -?
dam"""—N, o,SS" HIC Registration umber E pirat n Date
HIC Company Name or HI Registrant a .(— rr r
o. Street \ ��OINfYOLG Gt�A� ��I [O ( ''0
p J ® l�r 9-3 //� Email ad ss
Ci own,State,ZIP l Telephone (p
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G L c,152 § 25C(�)
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 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 �05SB4
to act on my behalf,in all matters relative to work authorized by this building permit applicatio
w
Print a(Electronic Signature) Date
SECTION 7b:.OWNERt 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 understandin .
L t(rNwJW, �u 55"
Print Owner's or Authorized Agent's kjnae(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. ovg /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"maybe substituted for"Total Project Cost"