B-17-1066 - 0013 VISTA AVENUE - Building Permit The Commonwealth of Massachusetts ,
Board of Building Regulations and Standards ,;0 l �( ,
CITY OF
Ulf IMassachusetts State Building Code,;780'CMR . ,.. 'SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,RenoV 1ComeB41i4a S 02
One-or Two-Family Dwelling _
This Section Fo Official Use Only,
Biiilduig Pernut:Number , Dat Applied: -
4 � f
Building Official(Print Name) Signature Date
- SECTION!:-SITE INFORMATION
q 1.1 Property Address: ..r .P 1.2 Assessors Map&Parcel Numbers
13 I)/STFI >9/)F �.541 FBI, ire�9 • elf V
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) T
6 r
Front Yard f . .l y e t ,. Side Yards ', ? Rear Yazd'.
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:;
C1 / Zone:.. .' _ Outside Flood Zone?
Public Gd -"Private❑ Check if yes0 Municipal o/On^site disposal system ❑
t SECTION1 --PROPERTY OWNERSHIPI
2.1 Owner'of Record:
1_09n1E374-PeP7e4 _ -P.97—T6a250,7 - 5�1 �'!A 0/97,!�2 .
Name(Print) City,State,ZIP
/3 al-5r,# 1*A5:,
No.and Street Telephone N Email Address
SECTION 3•'DESCRIPTION;OF PROPOSED WORKZ-(check allabat apply)
-.
New Construction❑ Existing Building 0 :Owner-Occupied -Repairs(s) ❑ Alteration(s) ❑ Addition, ❑
Demolition ❑ Accessory Bldg.❑i., -Number_of Units Other ❑ Specify: ;r
Brief Description of Proposed Work?:
v r�dS 41E�W 9X/t7A76 ND
SECTION 4t ESTIMATED CONSTRUCTION COSTS
'Estimated Costs Official Use
Item s ,
(Labor'and Materials)-
1.Building $ 1 Buildmg Permit Fee $ Indicate how fee is deterifi n d
_-_ _ _g- _ O. ❑Standard City/Town Application Fee
2.Electrical $ ,
❑Total Protect Cost�(Item 6)x multiplier x
3.Plumbing $` t' `` '2 Other Fees $
4.Mechanical (HVAC) List
5.Mechanical (Fire '
Suppression)
$ Total All Fees $
Check No Check Amount Cash Amount
6.Total Project Cost: $ SW ❑paid m Full �Outstanding Balance Due:
� �j � lr P L-A,-;p -1-0 �, ®
SECTION 5 CONSTRUCTION SERVICESw
1
5.1 Construction Supervisor License(CSL)
`` l License Number Expiration Date
Name of CSL Holder
.,
List CSI Type(see below)
No:and Street-- _ - _ _ _ _ Type.: ..:.; _ Descnption:: .P
_.0 Unrestricted(Buildings up to 35,000 cu.ft.
' R Restricted 1&2 Family Dwelling -
City/Town,State,ZIP -- - _ - - M Masonry
RC Roofing Covering
` WS Window and Siding •. _JV
SF Solid Fuel Burning Appliances - ! --
` I Insulation •Telephone i 'Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) -
HIC Registration Number ~ - Expiration Date'
HIC Company Name or HIC Registrant Name Vit -3 s * ,• ;;y c. •. - +
No.and Street Email address'
j 9
City/Town,State,ZIP Telephone
SECTION 6 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G L c';152 § 25C(�) .;
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 Attacfied? Ves..t.......❑.r `'No °'.:...
t
.k, SECTION 7as`0WNER AUTHORIZATION_TO BE COMPLETED WHEN {
OWNER'S AGENT OR CONTRACTOR;APPLIESFOR BUII,DING,PERMIT
Ias Owner of the subject property,hereby ahorize. .
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) - —•- _____. w.__ _ __ _,- ._. _._ .Date
' SECTION 7b._OWNER'ORAUTHORIZED,AGENT DECLARATION,„
By entering my name below,I hereby attest under the pains and penalties of petjury.that all of the information;,*• .. .'
contained in this applicati n is true and accurate to the best of my knowledge and-understanding. . . . +
Print wner's or Authorized Agent's Name(Electronic Signature) Date
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 o'nthe HIC Program can be found at
www.mass. og v/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.) i'' 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 ,,,; t•f,,,I Enclosed
3, - ",Total Project'Square Footage"maybe substituted for."Total Prcject,CoA.
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