B-17-745 - 0017 VISTA AVENUE - Building Permitr
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u • � L+ The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
1 b. Massachusetts State Building Code, 780 CMR SALEM
0 Revised Mar 2011
Building Permit Application To Construct, Repair,Renovate Or Demolish a
if One-or Two-Family Dwelling
This Section For Official`Use Only
Buldin Permit.Number:g Date pphed
Building,Official,(PrintName) Signaturebate
l SECTION 1 r SITE INFORMATION. :`
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
""7T\l s Pojv__ aloe F MR
I.Ia Is this an accepted street9 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:
Public❑ Private❑ Zone: Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes[]
w SEG'T10N 2:"'PROPERTY NERSHIP!
2.1 Owner'of Record:
Name(Print) City,State,ZIP
V S PCy�e_. on T—.On q-- y st r\q mow\i
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK?(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
umb Demolition ❑ Accessory Bldg.❑ Ner of Units Other Specify: - -
Brief Description of Proposed WorkZ:
y d
a
SECTION 4 ESTIMATED,CONSTRUCTION COSTS ,
Estimated Costs:
Item Official Use'Only
(Labor and Materials)
1.Building $ 1 J`.Buildmg.Perrn�tFee $ lndieate how fee is,determined:
2.Electrical $
❑;Standard City/TownApplicatton Fee
O Total Projecf Costa([tem 6)x multiplier X
3.Plumbing $ 2 Other Fees :$
4.Mechanical (HVAC) $ 'List
5.Mechanical (Fire
Su ression $ Total A. Il Fees::$
' Check No Check Amount Cash Amount
6.Total Project Cost: $ --� ❑Paid m Full a; ❑Outstanding Balance Due
.. m
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
CS-OSq B'8 a _(1-I I' --E3 1-7
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) U
No.and Street Type < Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
D0- ." T-s . MfA CD «Q—.� Restricted 1&2 FamilyDwelling
City/Town,State,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
cA7IT-92'2--cAam(4 aLr-c-cLs��123 1 I Insulation
Telephone Email address V�er j34hN D Demolition
5.2 Registered Home Improvement Contractor(HIC) ne
R -C• Q-0 -Vk-o— C. • HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
1 an Mo c-Yr �siA I-{t' ?A-ACL 'Z3 �
N .and Street 0 Email address
City/Town,State,►2IP Tele hone
:SECTION,'6:WORKERS'COMPENSATION INSURANCE AFFH)AVIT(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 a building permit.
Signed Affidavit Attached? Yes .......... No .........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED"WHEN
OWNEWS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize R C`_ (��.�-�� � l S�e SWyr\8 eA
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic ignature) Date
SECTION°7b OWN,ER'ORAUTHORIZED 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.
_ 1LY-�S e. SW\r\Ae\� - �K 1,%-
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
www-.niass.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"may be substituted for"Total Project Cost"
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