B-17-335 - 0033 BOARDMAN STREET - Building Permiti
2-o5 GA�_ 21 32 3
The Commonwealth of Massachusetts
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Board of Building Regulations and Standards CITY OF
�!,!? 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
Building Permit Number: -Date Ap ied:
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Building Official(Print Name) •Signature Wte
.
SECTION 1:SITE INFORMATION
1.1 Property Addres 1.2 Assessors Map&Parcel Numbers
J_ MA V1
1.1a 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?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Own ` f Rec d e
Name(Prin`-t)).. 'City,VaA,71V
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WO
RKZ(check that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory . ❑ Number of Units Other ❑ S ecify:
Brief Description of Proposed Work'': °
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: r
Official Use Only
(Labor and Materials)
1.Building $ 1. Bulding`PermitFee:$ Indicate how fee:is determined:.
❑Standard City/Town Application Fee
2.Electrical $
❑Total Project Costa(Item 6)x Multiplier-' x
3.Plumbing $ 2..Otlie"r Fees: $ -
4.Mechanical (HVAC)
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check'No. Check Amount: Cash Amount:,
6.Total Project Cost: $ ❑Paid in Fult 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) nfn
/ '� xp. License umber E tioJ Date
Name of CS oide �•��"[[�� �
List CSL Type(see below)
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No.an treet —� Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
14 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
cl �J � I Insulation
Telephone' ` �'�� Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) _
" F
HI� hon Number E pi Jn Date
HIC CM Name or strant A me
No.and Skre t
A, �- r 0 Email address
City/Town,State,ZIP T—e(lephon_a
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 Issn2 of the building permit.
Signed Affidavit Attached? Yes ..........d 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 Z , ing
to act on my behalf,in all matters relative to work authorized by this uilding 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 perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Pnnt Owner's or Authors ed 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.eov/oca Information on the Construction Supervisor License can be found at w,,vw.mass.gov/d s
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"
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