B-17-472 - 0048 BROADWAY - Building Permit -The Commonwealth of Massachusetts CITY OF~
Board of Building Regulations and Standards .SALErVI
4Yi Massachusetts State Building Code,780 CMR Revised Vhir 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
- One-or Tivo-Family Drvelling
.This Section For Official Use Only, '::.A t
Building-Permit Number:
1
Building Official(Print Name).�' Signature Date
1 - SECTION 1 SITE INFORINIATIOW.
1.1 Property_A ress: - - 1.2 Assessors Nlap&Parcel Numbers
Ma f #
I.la Is this. accepted street9 yes no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions: a
Zoning District Proposed Use Lot Area(sq 11) 'I) `, ! yfj0,tag j,t)
1.5 Building Setbacks(ft)
Front Yard 'Side Yards' = Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40;§54) 1.7 Flood Zone Iriformationi 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?_ Munici nl❑ On site dis osal s stem ❑
Public❑ Private❑ — Check if es❑ p p y
SECTION 2: PROPERTY OWNERSHW`
2,1 Owne �of Record:
G�
1��1me(Print) City,State,ZIP
No.and Strcet. Telephone Email Address
_ SECTION 3: DESCRIPTION OF PROPOSED WORIV-(check all that apply)
New Construction❑ Existing Building,❑ Owner-Occupied q 1 Repairs(s) ❑ I Alterttion(s) ❑ -Addition,❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work-:
•I s,LOD gg C
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Itcn�< Estimated Costs: µ Official Use Only
Labor and Materials)
1.Building $ j g' OM I.,Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee .
2.Electrical S ❑Total Project Cost(item 6)x multiplier x
3.Plumbing S 2. Other Fees: S ,
4.Xlechanical (11VAC) S List:
5.\Mechanical (Fire 5 'total All Fees:S
Su ressiun)
Check No. _Check Amount: Cash Amount:
G. '1'ut:rl 1'rojcct Cost: s ��V vv- ❑Paid in Full O Outstandin;Balance Due:
(O I M At L_e-U "1b 1J► L_
' o
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) j`7
a License Number Expiration Date
Name of CSL Holder Eric W. Palm List CSL Type(see below) :J
Is oil+ten-�i'',}' — Type. . Description .
No.:md Street Salem,MA'01970 U Unn'stricted Duildin a to 35,00 cu. ft.
w R Restricted 1&2 Family Dwelling
City/Town,State,ZIP Masonry
RC Roolinit Covering..
WS Window and Siding
- SF Solid Fuel Burning Appliances
7�
( / a. *7"(/1" 9�(� 3 '. - I Insulation
Telephone Email address D Demolition.
5.2 Registered Home Improvement Contractor(HIC)' JZ �9-
Mantic Weathelrization,LLC HIC Registration Number Expiration Date
Enc cumpany Namiklwar Menue '
Nu:Arid Street' Email address
Cityfrown,State ZIP Telephone -
SECTION 6:WORKERS'.CONIPENSATION INSURANCE AFFIDAVIT .L.(M.G c.152.123C(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 Isguance of a building permit.
Signed Affidavit Attached? Yes'.......... No..:........❑
SECTION 7u:OWNER AUTHORIZATION TO BE.CONIPLETED.WHEN.
OWNER'S AGENT OR CONTRACTOIfA PLIES FOR BUILDING.PERMIT
1,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 wner's Name(Electronic Signature) Date
SECTION 7b:OWNEW 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' this application ue�.and accurate to the best of my knowledge and understanding.
Print Uwner's or Authorized Agent's'Tie(Electronic Signature) - Date
.NOTES: '
I.• 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 nu have access to the arbitration
program or guaranty fund under NLG.L.c. 142A.Other important information,on the HIC Program can be found at
wwxv.mass.eov!ooa Information on the Construction Supervisor License can be found at
2. When substantial work is planned,provide the information below:
"rotai floor area(sq.ft.) (including garage,finished basetnenttattics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms t Number of half/baths
Type of heating system . Number of,deckst porches
'type of cooling system ~, Enclosed. Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"