B-17-812 - 0022 BOARDMAN STREET - Building Permiti
Quo
the Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards, , -,, SALEM
� w tt
Massachuses State Building Code,780 CMR
(X/ 4 i Revised,Clue 2011
�)/ r Building Permit Application To Construct, Repair, Renovate'Or Demolish a - -
` - One-o'r Two-Family Dwelling
This See ioti-For Official Use Only
_
l Building Permit Number: -- Date .P-Plied'
Building Official(Print Name).- . r'-: Signature ' . Date
r
SECTION 1iSITE`INFORMATION; c>° '
1.1 Property Address, ,:- 1.2 Assessors,tilap 3r.Pnrcel N
-� _ umbers
_ R r
I.la is this an accepted street yes no Map Number Parcel Number _
CIA
1.3 Zoning Informatio'ni` ` ` 1.4 Property Dimensions:
Zoning District Proposed Use - Lot'Area(sq tt) •• -_ .-Frontage(It)•
1.5 Building Setbacks(ft) --
Front Yard Side Yards _ _ Rear Yard
Required Provided - Required.'. . `Provided Required l Provided ,
1.6 Water Supply:(M.G.L c.40,§54) -1.7 Flood Zone Information:. 1.8 Sewage Disposal System:
Zone: Outside Flood Zone? - Municipal❑ On+site disposal system ❑-
Public❑ Private O .'. - - _ _ Check ifyes0 p p Y
:.,•.SECTION2: PROPERTYOWNERSHIPI`° -
2.1 Owperl of Recgrd: /
time(Print' Ciity,State,ZIP'
I •y
No.and Street Telephone _ t Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check ill that npply) —
New Construction❑ Existing Building❑ Owner-Occupied-❑ Repaiis(s)'0' 1 Alteration(s)-0 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work-: Oa5 � •
CAI w(asL `F��d�, l( 47 0 .
- SECTION a:ESTEMATED CONSTRUCTION COSTS
Item Estimated Costs: , Ofticiitl Use Only'.
Labor and Materials)
1.BuildingS 1. Building Permit Fee:S' Indicate how feeds determined:
❑Standard Cityffgivn.Application Fee
2.Electrical S ❑Total Project Costa(ttem 6)x multiplier - x
3.Plumbing S _ 2. Other Fees: S
4.M&6anical '(FIVAQ S List:
5.,Mechanical (Eire 3 total All Fees:S
Suppression)
Check No.13kaCheck Amount: Cash Amount:
6.'Ibtai Project Cost: .� ��a` O Paid in Full. 0 Outstanding Balance Due:
SECTION 5:..CONS7rRUCTION SERVICES 5.1 Construction Supervisor License(CSL)' , 3 f
e License Number Expiration Date
Name of CSL Folder List CSL Type(see below) c
Description . .
No.imJ Street - ' -- Unrestricted DuilJin u to 35,000 cu.ft.
:.R _ Restricted•1&2 Family Dwelling .
City/rown,State,ZIP ivi Masontry
-- -- -- RC Roolins Covering.,
WS -Window and Siding
SF Solid Ftiel Burning Appliances
I Insulation '
Telephone Email address _ D Demolition
5.2 Registered Home Improvement Contractor(HIC) -.*-, ' /-f )-b'Z-1
FIIC Registration Number Expiration Date
I IIC Cun�p;`y Name or H(C�Registrant� N3ma
NO.ai d Stre�r� _ Email address -
Cit Frown State ZIP Telephone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M:G,.L.c.15Z.$25C(t7)..
Workers Compensation Insurance affidavit must be co pleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Is§uance the building permit. ..,
Signed A lidavit Attached? Yes:......... No...........D
SECTION 7u:OWNER AUTHORIZATIOX TO BE_COMPLETED.W HEN, T -
OWNER'S'AGENTORCONTRACTORAPPLIES.FOR BUILDING.PER MI
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Date
Print Owner's Name(Electronic Signature)
- SECTION 7b:'OWNERt OR AUTHORIZED AGENT DECLARATION
By entering my name below,I herebyaitest tinder the pains and penalties of perjury that all of the information
contained in this application is trueand accurate to the best of my knowledge and understanding.-
.
Date
Print Owner's or Authorized Agent's Name(Electronic Signature)
- 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 Honte Improvement Contrnctor,(HIC)Program),will not have access to the arbitration t
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can 6e foundtat
�aww ntas-. ov"•'oca Information on the Construction Supervisor License can be found at www.ntassalov'�_. _
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
Ntimber of fireplaces Number of
Number of bathrooms Number of half/baths
type of heating system `lumber of decks/porches
type of cooling system
4 ' Enclosed Open
1. "total Project Square Foota;e"may be substituted for"foal Project Cost"