B-17-337 - 0009 QUEENSBARY DRIVE - Building Permit i
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The Commonwealth of Massachusetts
��V '� Board of Building Regulations and Standards
g CITY OF
`� 1f Massachusetts State BuildingCode 780 CMR SALEM
Revised Mar ZOl!
Building Permit Application To Construct, Repair,Renovate Or Demolish a
�— One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: ate Applied
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Building Official(Print Name) " Signature Date
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SECTION'-1:SITE INFORMATION
1.1 Pro erty ress: 1.2 Assessors Map&Parcel Numbers
l.l a Is this an accepted street?y s 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? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP.
2.1 Owi of TTt:
/� P
Name(Prirtit);* 'City, at I
No.and Stket et Telex o e Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units ther ❑ Specify:
Brief Description of Proposed Work'': ("
SECTION C ESTIMATED CONSTRUCTION.COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1.Building $ 1.1.Building Permit Fee:.$ -hrdicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ .
❑.Total Project Costa(Item 6)-x multiplier x
3.Plumbing $ 2. Other Fees:
4.Mechanical (HVAC)
5.Mechanical (Fire $
Suppression Total'All Fees:$ '
Check No Check Amount: Cash Amount:.
6.Total Project Cost: $ ❑Paid in Full' L ❑Outstanding Balance Due: -
`' t L1 VV n- Lim 1-0
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
2",1, 6=�,, License Number Ex ra' n Date
Name of CSL Holder
List CSL Type(see below) W S
`
No.and S`treeete Type Description
— T e
U Unrestricted(Buildings up to 35,000 cu.ft.)
City/Town,State,ZIP R Restricted 1&2 FamilyDwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Tele hone�"' Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
F�
HIC Registration Number E pi hon Date
HIC CM Name or strant me
No.and Are t U .� Email address
City/Town,State,ZIP Tele hon—e
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 IssuT2 of the building permit.
Signed Affidavit Attached? Yes .......... 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_
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.
c � 4&1)-7
Print Owner's or Authorized 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
�vww.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
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"maybe substituted for"Total Project Cost"