B-17-771 - 0039 VALIANT WAY - Building Permit 3z��2- cocfz�
r �3i 'a `? Commonwealth of Massachusetts
a ' Board of Building Regulations and Standards CITY OF
�M�ss usetts State Building Code,780 CMR SALEM
� ,� 1 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 Number: Date Applie
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1 1.1 ]Property Address: 1.2 Assessors Map&Parcel Numbers
1.1 a 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 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 El
SECTION 2: PROPERTY OWNERSIHP1
Vz 2 Ownert of Reco d:
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Name(Print) City,State,Z
` Va.�1a� �y q�Cs-�oa=olt�3 kuVg P -.37 gyria<<.Cy
No.and Street Telephone IEmail Addres
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units I Other ❑ Specify:
Brief Description of Proposed Work':
Orl(1( F S GJ
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ '3 3 7 7 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ t 0 d 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Suppression)
3 C 7 Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ J ❑Paid in Full ❑Outstanding Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
Ck✓1 S `e/V, n G" License Number Expiration D to d
Name of CSL Holder
— L9 Of
CS a / / List CSL Type(see below) V
No.and treet l ( Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.p�
� &Ar- R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
C�tr.S /`a/SOP�v r(f�l�j SF Solid Fuel Burning Appliances
9[. ewcw-s q Cc I Insulation
Telephone Email address D Demolition
5.2('R,,egistered Home Improvement Contractor(HIC) f•r_ Z�S� 2�
CAV-L1 5 O IVL ail A"� 0e-s�sN HIC Registration Number Expiration ate
HIC Company Name or HIC Reg' trant Name /�'
SC4 0A Cc s Ct,Q&-vL 1 4 S Q 60--
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No.and Street Email address
Ci gown,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 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
1,as Owner of the subject property,hereby authorize L l
to o my behalf, a 1 matters relative to work authorized by this building permit plication. /--�
l t
MR Owner's 4aine(Electronic Signature) I Ilate
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�r, 5fz)A �. c�.Uso �It? Lz-o /
Print Owner's or Authorized Agent's Name(Electronic Signature) bate
NOTES:
l. 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
www.mass.gov/oc 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,fmished 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"
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Main Level
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