B-17-1205 - 0001 BLOCK HOUSE SQUARE - Building Permit .yZ _
l
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
(� One-or Two-Family Dwelling
U ` This Section For Official Use Only
O Building Permit Number: Date A plied:'
1 Building Official"(Print Name) Signature Date
SECTION SITE;INFORMATION
1.1 Property ress• 1.2 Assessors Map&Parcel Numbers
- n1ok
(`� l 1.1 a Is this an accepted street?yes n 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'of Rec rd•
Name(,Print) City,State, 1P
L
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check ap that apply) "
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ ecify:
Brief Description of Proposed WorO:
! VA
SECTION 4:ESTIMATED;CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only.
Labor and Materials
1.Building $ �- 1."Building Permit Fee: $ riidicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $
❑Total Project Costa(Item 6)x multiplier, x
3.Plumbing $
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:
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
-- � Licenle"Number Exp' ti n Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
1/ 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
7:0�, L I Insulation
Tele one Email address D Demolition
5.2 Registered Home Improvemen hatio"t Contractor(HIC) _ ,
to)t Xf 1 HIC Regis n Number Expi io ate
HIC Com an Name or H1C��1 a t ame
No. nd Str® t Email address
City/Town,State,ZIP 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 Issuanc f the building permit.
Signed Affidavit Attached? Yes ..........te, No...........❑
SECTION 7ai OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR'CON.TRACTOR APPLIES.FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize i Ljly)Al
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:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contame t ISlication is true and accurate.to the best of my knowledge and understanding.
is r u onzed Agent's Name(Electronic Signature) Dr e
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.eov/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.fi.) 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"