B-17-1085 - 0004 BERUBE ROAD - Building Permit rP G(< zS l
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The Commonwealth of Massachusetts
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Board of Building Regulations and Standarc)s"- CITY OF
Massachusetts State Building Code,780 CMR SALEM
���� t _ i ; wised Mar 2011
(�O Building Permit Application To Construct,Repair,Ren(We'OrjDe 3olissh a
One-or Two-Family Dwelling
�. This Section For Official Use Only..
t Building Permit Number. Date,:: P ted.
Building Official(Print Name) Signature Date-
SECTION,1:SITE INFORMATION
1.1 Property Addres 1.2 Assessors Map&Parcel Numbers
1.1 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':
2.1 Owner'o ecord:
h -
Name(Print) 7 City Stite,ZIP
6 Z!%- e W .
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION PROPOSED WORK?(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ FAddition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Workz: AN Jh,
SECTION 4-ESTIMATEDYCONSTRUCTION COSTS' -
Estimated Costs:
Item ;Official Use Only
Labor and Materials ,
1.Building $ 1 -Building"Permit Fee $ Indicate how fee is determined
❑Standard City/T6wn Appl cation Fee ,
2.Electrical $ r
❑Total Project Cost•,(Item.6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ "Ltst:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Cheek.Amount � Cash Amount
6.Total Project Cost: $ ❑Paid,tn Full; ❑Outstanding Balance Due:
t� II Mn���� -1 ,p
SECTION 5:`CONSTRUCTION SERVICES ,.
5.1 Construction Supervisor License(CSL)
Liic n e um er Ex on ate
Name of C er S List CSL Type(see below) (�
No and Stl�t — � Type. Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
City/Town, fate,ZIP R Restricted 1&2 FamilyDwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
0)915r 3 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registry ion Number pi4ioS Date
HIC Co any ame or C Re -strant Name
49 '¢
No.aqdStreet T - Email address
Ci /Town, e, P � 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 Issuan of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
OWNER AUTHORIZATION. TO BE COMPLETED WHEN
SECTION 7a:
=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:OWNEWiOR AUTHORIZED AGENT DECLARATION:
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contai in thIF application is true and accurate to the best of my knowledge and understanding.
177
ri erl or Au orized 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.govloca Information on the Construction Supervisor License can be found at www.mass.vov/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"may be substituted for"Total Project Cost"