B-17-850 - 0029 BOARDMAN STREET - Building Permit c,,g•l 3 0
The Commonwealth of Massachusetts
UIL
's` Board of Building Regulations and Standards CITY OF
y 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
This Section For Official Use Only *�T '
/1 Building Permit Number: Date App ied: 3
U�
1
' Building Official(Print Name) Signature DadeLn
f
�. SECTION 1:SITE INFORMATION 3 '
` 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers M
x\' 2q W ROMAM ss. , —CA LEA'-1 35-0 If 3
1.1 a Is this an accepted street?yes ✓ no Map Number Patcel PareeiNtunber
1.3 Zoning Information: 1.4 Property Dimensions: a '£
9 a t 6�- q 4n
n �T
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 NJ Private❑ Zone: _ Outside Flood Zone? Municipal 4P On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1Owner'of Rec rd:
DAVI D 3G�pCt s AN OR Z qjJ o I
Name(Print) City,State,ZIP
Gayn64
'5T
No.and Street. Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition [IDemolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of o osed Work2:
Q e�liyl,11 C, KA as o d & 5'
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item �. Official Use Only
Labor and Materials
r 1.Building $ o L�-O 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Applicati n Fee
`tom° ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ a cr(7 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire ' .
Su ression $ Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ g TOO." 11 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) c S— n$ 3 933 3-Z 6 Z f 9 Mat�tiGL License Number Expiration Date
Name of CSL flolder V
List CSL Type(see below)
S ys S T e Description
No.and Street
01970 U Unrestricted(Buildings up to 35,000 cu.ft.
Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
f p� J Z Y 4r qbn kJ SF Solid Fuel Burning Appliances
COW CC15�; N �' I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 1 7 ? 360
CHIC Registration Number Expiration Date
HI,Com any N e or C Registrant Name /
W 00
4 s S eFF ►all �g �CowtcaSf® �f°
No.and S eet Email address
Sa 1t t1 0/970 -
City/Town,State,ZIP Tele hone
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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... 0 No...........0
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'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of petjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Allfhorized Agent's Name(Electr(5nic 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. og v/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"may be substituted for"Total Project Cost"