B-19-204 - 0000 BAKERS ISLAND - Building Permit 25 cr-3cfos
The Commonvy-e lthofMassachusetts —
I h Board of Building F°.egulations and Standard; CITY OF
Massachusetts State Building Code, 780 0,113, SALEM
Revised Nlar Wll
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Tti�:r,-.l'tinily Dwelling-
This Sec.lion For Official:Use Onl.v
Building Permit Numbeir. -„_- Irate Applied:
Building Official(Print N-anti) Signature Date
_ SECT.iw� 1,SITE IN:FORMATI4 ,N
1.1 Property Address: -_-- -- 1.2 Assessors Map Parcel:Numbers ----
L to Is this an accepted street?yes_ no Map Number. Parcel Number
1..3 Zoning,Information: 1.4 Property Diateinsions: --
.pining District Proposed Use Lot Area(sq ft) — Frontage(ft)
' I.S Building Setbacks(ft:)--- ------ ------- -----
Front Yard Side'Yards Rear Yard
Required 1''rovided Required Provided Required Provided
1.6 Water'Supply: (M.GJ.,C.40,§54) 1.7 Flood alone Inforimation: 1.8 Sewage:Disposal System:
Zone: _ Outside Flood'Lone?
Public❑ Private❑ Check if yes❑ Pafunicipal❑ On site dispersal system ❑
--_- --- SECTION 2: F-111OPERTY OWNERSJHC-II'' -
2.1 Owner'of Record:---- -_- - ----
_ tR03rJ-J G-0`oo"tq rat&\A`{�NH_- 03Z3
Game(Print) ---- — City,State,ZIP --- — _
51 5t(4wAaC) Va— Q78-3S? —161\4 t�MG-b,,. ZN 67M5,N .cOM
No.and Street Telephone Email Addre
s,.
SECTION 3:DESCRIPTION rt
l F' (PROPOSED WORIlC` (check all that apply)
New Construction❑ I x.tsting Builclingx Oan.er•Occupied }1( Repairs(s) ❑ Alteration(s) 1K Addition ❑
Demolition ❑ Ac;cessory Bldg. ❑ Nu:ni6er of Units 01:lzer ❑ Specify:_ _
2:-- RE�—.A —
Brief Description ofPro o-ed Rork
W_. t)U3
SECTION 4.ESTI1.3•.1A I'ED CONSTRUCTPIYI l CONS ---
Estimated Costs:
Item Official Use Only
_... (Labor and Materials) ---- __
1. .13uilding g, 000.(X-> 1. Building Perini:t Fee $ _Indicate how fee is determined
-- - -- 1:1 Standard City/Town ikpplication Fee -,
Electrical �s .�-
1-1 Total Project Costa(It.m 6)x multiplier x:_
r fs
.i. Plumbing �` '. Other Fees: $.
t Mechanical (H`AC) ... _1; -- ---- ---- _` _
,i:st:
- - -
> Mechanical (Fire — — -- --.- - -
s u. ression) r Total All Fees: $
-_1. —-- — — --
Check No._ Check A.rnount:_ Cash.)mount:
6. Total Project Cost, $ 10 00. O� I=]Paid in Full 0(:)utstanding Balance Due.:
31(9 M c t-.6r-,) .t--0 H, p
SECTION 5: C'ONSTRUCTION SER:aTC;ES _.
� 5.1. Construction Su eir��---�— __..---•__--
p r isor License(CSL)
License Nucriber Expiration.Date
Name of CSI.Holder
List CSL T`;pe(see below)
.No.and Street
Type Descripticoi
U _Cnrestricted{Buildings�T?to 35,000 cc}.ft.)
R F:estricted l&2 Family I)welling —
Cir17/Town,.State,ZIP M Masonry —_—
_..___
RC ltoofmg Covering -
__-- -- -..__----- WS 'Window and Siding --
SF Solid Fuel Burning Applia.n.res
1 Insulation
Telephone _ _ Email address _ _D Demolition _
5.► Registered Home lmperovement Contractor(RIQ — —
IIIC Etegistration Number Expiration Date
HIC Company Name or HIC:Rsgistrant Name
No.and Street --------Iirnail address
City/Town,State,ZIP -_ _ --- —_--Telephone-- --
SEC1rION 6:W()11`KMRS' 0.-MPENSAT.11.0N INSUfUNCE AF:Ilr11FIA,`JI:T(M..G.L.c. 152 i 25C(6))
M/orkers Compensation Inst,trance affidavit must be co npleted and submitted withthis application. Failure,to provide
this affidavit will result:in.the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No........... 11
SECTI[(Jci'd 7a: OWNER AU71'I:II[t,tltl7.ATION TO BE C'Cpw[PILETEI➢WHEN .
OWNFKS AGENT OR CONTRACTOR APPLIES F0111 IF,-UtLDING PERMUF
1,as Owner of the subject property,hereby authoriz-r
to act on my behalf, in all matters relative to work a.u`:horized by this buildir 9 permit application.
Print Owner's Name(Electronic Signature;) Dale
SEC'I'llON 7b: OWNER' OIR 4.UTHORIZEO AGENT DECLAR?nTI:ON
By entering my name below,I hereby attest under the:pains and:penalties of penury that all of the inforun:ation
..ontained in this application'.is true and a
CQ.Urate t�o/the
_best of my knovi ledg,.; and understanding.
I'.rint Owner's or•Atrthorize:cl r,; ent's Na (Elect:ronic SiL;aa.ture) Date:
-- ---- NOTES: _
1. An Owner who obtains.a building permit to do his/her own work,or an o a,ner who hires an unregistered contractor
(not registered in the:Idorne Improvement Contrractor fHIC'a Program),r iCil root have access to the au kritration
pro-ram or guaranty fund under 1.q.G.L.c. I42.A.Other,important information on the HIC Program.(.an be found at
www.mass.gov/oca Int<rrmation on the Consfrt ct.ion Supervisor License c a:ra 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 basernent/attics,decks or porch)
Gross living area(sq.ft.) _ I-labitabl6e r,,om count
Number of fireplaces— _ Number of bedrooms _
"J'nmber of bathrooms Number of half/baths
rype of heating system _ —__ Number o;f decks/porches
Type of cooling system-_-_- Enclosed _ _— —Open
3. "Total Project Square Footage"may be' substituted for"Total Project Cost"
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