B-17-378 - 0012 BADLEY ROAD - Building Permit t Ci< i1 1. -16
The Commonwealth of Massachuset = t i �-
i,�� Board of Building Regulations and Standards CITY OF
• Massachusetts State Building Code,� 78g _ P SALEM Y U 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 Appli
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property d � s: 1.2 Assessors Map&Parcel Numbers
L I a Is this an accepted stree . 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 Cl Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owne�r n' f Re d:
Name(Print) City,State,ZIP
No.and Street a one P Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'.(check•alI that-apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs( Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
SECTION A-ESTIMATED.CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ l. Building Permit Fee> Indicate how fee is determined-
2.Electrical $ ❑Standard City/Town Applicaiion Fee
❑Total ProjOct:C6se(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: '$
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total All Fees:$ .
-Check No Check Amount• Cash Amount
6.Total Project Cost: $ ❑paid in Full ❑Outstanding Balance Due
f
SECTION:5:. CONSTRUCTION.
:SERVICES
5.1,Construction Supervisor License(CSL) `
1 ' Lice se N Exp do a e
Name of CSL Holder
`/�i List CSL Type(see below)
N .an etf 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
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration umber p" ion ate
HIC o pany e r Registrant Name
No.and tre t Email address
r
Ci own,State,Z elephone
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 the building permit.
Signed Affidavit Attached? Yes ......... Er No...........❑
SECTION 7a: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.
Print Owner's Name(Electronic Signature) , Date
SECTION:7b:OWNER 1:OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
co ' e application is true and accurate to the best of my knowledge and understanding.
's or An on 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 haWbaths
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"