B-19-356 - 0027 UPHAM STREET - Building Permit Z 2
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
SAULM
Massachusetts State Building Code,780 CMR a:.
Revised tl�dr 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
,. ,a
C(1 This Section For Official Use Only 7
1 Building Permit Number: bate Applied:
Building Official(Print Name) Signature " t5te r
...•SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
(17 UPh1�_M . 6/1
1.1 a Is this an accepted street?yes V----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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: e
JP,4,U * QRnT r,re AtTAq �7 U 66Y' `r' MA,5 S 0 V
Name(� — City,State,ZIP t
I-1a T,4 40,40 k
No.and Street Telephone Eradil AddF6ss
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Workz: - `oti
t
,tir 1 i v .¢ fC v�
�1 .v i icy
� S
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ i I z � 0 0 1. Building Permit Fee:$ Indicate how fee is determined: j
2.Electrical $ 06 06 ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 0 40. D 6 2. Other Fees: $
4.Mechanical (HVAC). $ List: � •��
5.Mechanical (Fire $
Su ression .Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ D00 Q 0 ❑Paid in Full: ❑Outstanding Balance Due:
-
C� �U� ��
SECTION 5:CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) S l3
��i . �` /`�✓ License Number Fxpuatio Date
Name of CSL/Holder List CSL Type(see below)
,m ,� �'► a Description
No.and Street
U Unrestricted uildin up to 35,000 cu.$ .
L Radcted M2 Fauul Dwe'llim
City own,S ZIP M J&C
RC Roofing Covering
WS window and Sidin
Co ction Supervisor's Signature or f lecimnic Signature) SF Solid Fuel Burning ApghLmices
P0Ior Demolition
non
Telephone Email address
5.2 Registered Home Improvement Contractor(HIC)
MF-piryJ qgs p � HIC on Number T� �iratioa Date
HI Compaay Name or C Registrant Name
It d Street HIC Reeshant's Signature
CWTT State,DP TeI hone
SECTION 6:WORKERS'COMPENSATION INSURANCE:A+ ►MAVIT(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 the building permit.
Signed Affidavit Attached? Yes............. No.............❑
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WBEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby anthmize . �✓/ �' to act on my
IF,
in matters relative work authorized by this bnfiding permit application
Owner's/Authorized Agent's Signature D
SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury tat all of the information contained in this
application is true and accurate to the best of my knowledge and understanding.
r
Owner's or Authorized Agent's Name or(Electronic Signature) Date
NOTES:
1.An owner who obtains a building permit to do his/her own,work;or as owner who hires an unregistered contractor(not
registered in the Home Improvement Cont,ractor.(HIC),will not have access.to the arbitration program or guaranty fund under
G.L.c. 142A. Other information about the HIC Program can be found at www.mass.gov/oca.Information on the Construction
Supervisor License(CSL)can be found at www.mass.aov/dvs..