B-17-369 - 0002 BORDER STREET - Building Permitr
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The Commonwealth of Massachusetts
Y OF
Board of Building Regulations and Standards SIALEM
Massachusetts State Building Code,780 CMR
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 NuiYiber a Applied
$uildmg Official(Print Name) Signature ,, Date
SE 71W.1' Stu-INFORMATIUIV> ;
1.1 P perty Address: 1.2 Assessors Map&Parcel Numbers
-SA.
1.Ia-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 j 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 OVNERSHIPt ,
2.1 O neri of Record: ff UU
N e(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIC2„(check all that;app,
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2:
C t
SECTION 4:..ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only '
Labor and Materials �•. A, _.,,.,
77
1.Building $ `T Building Permit Fee $ Indicate how fee is determined;
2.Electrical $ Standard City%Town tlpplicahon Fee
0 Total Project Costa(Item6)x multiplier x
3.Plumbing $ 2. Other Fees.'
4.Mechanical (HVAC) $
5.Mechanical (Fire $Sression) Total All Fees:$
_ Check No Cheek Amount: Cash Amount
6.To al Project Cost: $ H ms 0 Paid in Full 0 Outstanding Balance D.ue.
SECTION 5: CONS'1'RUCfION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder List CSL Type(see below)
Type Description ..
No.emd Street
U Unrestricted(Buildings tig to 35,000 cu. tt.
R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP �Il Masonry
RC Roolinit Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
! Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expirution Date
I IIC Company Name or HIC Registrant Name
No.and Street Email address
City/Tow State ZIP Telephone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152.125C(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 Istuance of the building permit.
Signed Affidavit Attached? Yes..........C3 No O
SECTION 7n.OWNER AUTHORIZATION TO BE.COMPLETED.W HEN:`
OWNER'S AGENT OR CONTRACTOR:APPLIES FOR BUILDING.PtRNIIT
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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:dWNERt 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 est of my knowledge and understanding.
Print Owne •or Authorized Agent's Nam (Electronic Si attire Date
NOT Sr
I. An Owner who obtains a building permit to do his/her, wn work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program);will nu have access to the arbitration
program or guaranty fund under 1I.G.L,c. 1 d2A.Other important information on the HIC Program can be found at
%vww.mass.�v!ocut Information on the Construction Supervisor License can be.found at%V%vw.mass.(ov/I .
2. When substantial work is planned,provide the information below:
"total fluor area(sq. R.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. tl.) 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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