B-17-508 - 0013 VISTA AVENUE - Building Permit ob
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The Commonwealth of Massachusetts. NU I
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Board of Building Regulations and Standards SALEM
ul Massachusetts State Building Code,780 CMR s 011
Building Permit Application To Construct,Repair,Renovate Or g6AA0l3*a- 3
One-or Two-Family Dwelling
Ttus SecCioe 1 vr.Offical,LTse Oi ,
Biildmg Permit Number
C� $wldw (lc�al t Name ---L U ) h. � ) • . S Date
J SICTION.;1 SITE)€NPO-RIATIQN
1.1 P operty Address: 1.2 Assessors Map&Parcel Numbers
J rP1SY4 19045.
( � 1.1a 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 00
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?
Check if yes❑ Municipal❑ On site disposal system ❑
5ECTIQIV 2: PROEERTY OV�IVERSII<IP :
2.1 Owner'of Record:
7�3/+tES Ddyi✓Ft PAT>�2S�✓! 5-f v1 i -r4-f 0/g 70
Name(Print) City State,ZIP
No.and Street Telephone Email Address
SECTION 3 DESCRIPTION OF PROPOSED WORK2(check all that. apply).
New Construction❑ Existing Building)l Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other_ ❑ Specify:
Brief Description of Proposed Work2: eA?0 1 � ✓ 51,01116 C'KI,1? Ai2Of
SECTION 4:ESTE14ATED.CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 149 per; 1. Building Pena t Fee $.:: Indicate how fee ts.determtnecl
2.Electrical $ Stamm Ctty ownApplicationFee
Q Total Project Costa(Iteria 6)x miulttpher x.
3.Plumbing $ 2. Other Pees $ .
4.Mechanical (HVAC) $ List
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No. Cheek Amount: Cash Amount:.
6.Total Project Cost: $ /U/ 0` f�• p Paid in Full O Outstanding Balance Due
rArA L t,V'D U i Z d� V l STP �v
f
SECTIONS: CONSTRUCTION SERVICES
S.I aConstruction Supervisor License(CSL)
77 License Numbcr Expiration Date
Name of CSL Holder List CSL Type(see bclow)
Type. Description .
No.and Street
U Unrestricted(Buildings rn to 33 000 cu. It.
` R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP M ,bfaso
RC Rooting Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IIIC Company Name or HIC Registrant Name
No.and Street Email address
Cityfrown,State ZIP Telephone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M:G.L c.15Z.§2$C(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 Is§uance of the building permit.
Signed Affidavit Attached? Yes..........O No...........O
SECTION 7a:OWN ER.�UTHORIZATION TO BE COMPLETED.WHEN:'
OWNEWS AGENT OR COSrr9A' CTOltlt APPLIES-FOR'BUIL,DING.PEILNIIT
I,as Owner of the subject property,hereby authorise -
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:dWNERt 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.
Print Owner's or authorized Agent's Name(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 rru have access to the arbitration
program or guaranty fund under I.G.L.c. 1 d2A.Other important information on the HIC Program can be found at
%.ww.maus.cov,'oca Information on the Construction Supervisor License can be.found at%v%vw.mass.gov/dns .
a 2. When substantial work is pl..mncd,provide the information below:
'total floor area(sq.ft.) __ N (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"may be,ubstituted I'or"Total Project Cost"