11 ABBOTT ST - BPA-16-12836 INSULATION L Lq�1, a o
---,G< 128 35
9 The Commonwealth of Massachusetts
9 Board of Building Regulations and Standards CITY OF
A � Massachusetts State Building Code, 780 CMR SALEM
�Q Revised 4hir 2011
N Building Permit Application To Construct, Repair,Renovate Or Demolish a
One-or Tivo-Family Dwelling , o
i This Section For Official Use,Onty_ R
F�Ialis
g Permit Number. DateApplteds
ry
g Official(Print Name) SECTION 1 SITEINFORMATIOpFer b /less. 1.2 Assessors:�lap&Parcel Numbers -nO is an acre ted street?yes no Mop Numbrr, t ri Pp,., t: ,i;,; itnglnformation: 1.4 Properlpflimeaslanstl-ij'A, !' (t)
strict c Proposed Use LoCArea(sq R) 'f FFaotoge(R)
L5 Building Setbacks(R)
Front Yard Side Yards Rear Yonl
Required - Provided ,Required Provided. Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information, L8 Sewage Disposal System:
Pofbiic O Private O. Zone: - Outside Flood Zone? Municipal Q On site disposalsyIitem O
Chedcif C.. .-
SECTIONZ: PROPERTY:OWNERSHIP"
2.1 j(Print)
rl h;
O Cily,State,ZIP
kLNo - Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKS(cheek all that apply)',
New Construction O Existing Building O Owoer•Occupied O Repairs(,) O iteradon(s) 0 Addition ❑
Demolition ❑ Accessory Bldg.O . Number of Units Other Specify:
Brief Description of Proposed Wo/'r�k�=: -
IMM IIS
_ -
SECTION 4:ESUNIATED CONSTRUCTION COSTS
Win (Labor
Costs: Official Use Only
Labor and Materials
1.Building IS 71 fojJ, 1. Building Permit Fee:S Indicate how fee is determined:
2.Electrical - s - ❑Standard Chyli'own Application Fee._
❑Total Project Coss'(item 6)x multiplier x
3.Plumbing I s ?)Qther Fees: S
4,Mechanical (FIVAC) S List:
5.,h1echanie:d (Fire _ s -
Suppression) Total All Fees:S
Check No.II9.RSCheckAmount: Cash Amount_
6.Totdl Project Cost: s p Paid in Full ❑Outstanding Balance Due:
I( � � MAlt�lp IN StaS�
SECTION 5: CONS'rRUCTION"SERVICES /
5.1 Construction Supervisor License(CSL) 7 ?-77 N 17- 3
Licinse Number Expiration Date"
Name ofCSL[folder EflGW.Pahn LisvCSL-rype(see below)
Type" Description ._ .
No.:md Street Salon MA MIFO U Unreslthaed Buildin a to 35,000 w. R.
c, R Rtedl&2Famil Dwelling
estric
Cit /Town,State,ZIP tvi aso
.�, RC Rooli Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
q_�-7 .'7111-f, 9—/ 14 � 1 fnsulolion
Tcle hone Email address D Demolition
V 5.2 Registered.Home Improvement Contractor HIC) � (/Z a
10 )"^ FIIC Registration Number Expiration Date
f I Company Name o.
Email address
No.mid Street - .. .
Ci /town State ZIP Tel Norte
SECTION 6rWOR[CERS'.COhIPENSATION:INSURANCEAFFIDAVIT(M.G.,:c:152 125C(6)1
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will,result in the denial of the Istuance o uilding permit.
Signed Affidavit ARnched? Yes.......... No...........❑
SECTION 7tl:OWNERAUTt10Rl2ATlON.TO BE.COMPt ETED}VHEN'".T;:'
OWNER'S AGENT OR CONTRACTORAPPLIESFOR BU"blt4 .PERhl't'
1,as Owner of the subject property,hereby authorize
«)act on my behalf,in all matters relative to work authorized by this building permit application.
� a �.� l l Z
/►'I am(E i Date
Print Owner's Name(Eleeuonrc$�gnature)
SECTION 7b:OWNERr 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.
Dale
Print Owne s�diurized A�€ " a kYtronic Signalurc)
NOTESr
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 Mg have access to the arbitration
program or guaranty fund under VLG.L.c. Ia2A.Other Important inforrt r no f a rogram can 'etoTiftt7 t�
wiwv m;as.eov'oca information on the Construction Supervisor License can be found at wwa•.mass.eovhlns -
2. When substantial work is planned,provide the information belay:
total door area(sq.R.) N (including garage,finished basement/attics,decks or porch)
Habitable room count
Gross livirig area(sq. It.)
Number of fireplaces Number of bedrooms
Number of bathrooms Number of deccks!half/baths
'type of heating system Number of d porches
rype of cooling syste Cnciosed" Open
m
1 `Total Project Square Footage"may be substihiled I"ur"'total Project Cost"
I