B-17-826 - 0033 BRIGGS STREET - Building Permit The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date A !1d:
Building.Official(Print Name) Signature
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1.1a Is this an accepted street? es^ p y JV no Map Number Parcel Number
13 Zoning Information: 1.4 Property.Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(11)
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 0 Zone: _ Outside Flood Zone?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: �
M A �(?
Name(Print) City,State,ZIP
No.and Street
Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WOW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
BriefQ�esc__ription of Proposed Work:_ 1P E1w c„n v'7 RA_�( .j
LLF,Y�LtOts ) irJl► 1
SECTION 4:.ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 0oo 1. Building Permit Fee:$ , Cg.aa Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
��3.Plumbing ❑Total Project Costa(Item 6).x multiplier x
$ 1.!7.
o 2. 'Other Fees: $'
4.Mechanical (HVAC) $ List:
S.Mechanical (Fire
Suppression) $ Total All.Fees:$
Check No. Check Amount: Cash.Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding.Balance Due:
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
" I e-TC 1d2� !'�. L- License Number Expi tion Date
Name of CSL Holder
1 6 fs'e�nr�.�.Apt List CSL Type(see below)
No.and Street Type Description
5;4&041 M A . Qlcm Unrestricted(Buildings u to 35.000 cu.ft:
City/Town,State,Zip R Restricted 1&2 Fami1 Dwellin
M Masonry
RC Koohng Covering
VS Window and Siding
SF Solid Fuel Burning Appliances
C6irr�lES`i •A' 'I� I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
/M'3 96 7/
HIC Company N e or HIC Regi " tName HIC Registration Number xpir tion Date
No.and treet Aler
CVk Mq 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 Issuance of building permit.
Signed Affidavit Attached? Yes..........❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE"COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize ( i~`CZ IZ 1-I(1~tL_
to act on my behalf,in all matters relative to work authorized by this building permit application.
C-3 r7
Print Owner's Name(Electronic ignature) — are
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 accuratetq the best ofmy knowledge and understanding.
Print Owner s or Authorved Agent's Name(Eectronic Signature) are
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 spot have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the MC Program can be found at
wunv.mass.cov/oca Information on the Construction Supervisor License can be found at%w%k,%v.mass.,gov/dos
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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