23 ABBOTT ST - BPA-14-428 ROOF � 7
The Commonwealth of Massachusetts
Board of Building Regulations and Standards SCY OF
Massachusetts State Building Code, 780 CNIR SALEM
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,Applied.,, I i. "?:i = ! ?;
lZZI 13
Building Official(Print Nay e) e Date -
SECTION I:SITE INFORMATION
1.1 Property Address: 1,2 Assessors Map& Parcel Numbers
Q '3 A bb o Kx- S-c--
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(tt)
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❑
SECTION 2:, PROPERTY'OWNERSHD?L'
2.1 Ownert of Record: [+ �n
J' A
Name(Print) C.-C.ity,State,ZIP
Z Y-i S
No.and Street ` Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ FExisting Buildin Owner-Occttpie Repairs(s) Alteration(s) ❑ I Addition ❑
Demolition ❑ I Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of ProposedlVorkt: -17-7-4ztTq LL g=
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only%
Labor and Materials
I. Building 5 15—as moo I. Building Permit Fee:S Indicate how fee is determined:
❑Standard.CityfCown Application Fee
2. Electrical $
❑'Coral Project Costr(Item 6)x multiplier x
J. Plumbing S 2. Other Pees: S
I. Mechanical (IIVAQ S List:
i. Mcchmnical (Piro
Sn t reiviun S 'futal :111 Pecs:S_
Check No. _Check Amount: Cash Amount
fatal Project Cost $ O Paid in Pill ❑Outstanding I)olnnm Dnc:
Tv co 1a-rni��-rv�
r
SEcrION 5: CO:NS'l-RUCTION SERVICES
5.1 Construction Supervisor Lieense(CSL)
T ]'b Li'C License Number Expiration Dane
Name of CSL fielder
List CSL Type(see below)
2 type Description
No. and Street
U Unrestricted(Buildings u to 35,000 cu. II
�_ .o,q C p t�1� � 0 ( 9 g� R Restricted 1&2 Family Dwelling
City/lrown, State,ZIP lyI Masonry
RC Roofing Covering
WS Window ;ihd,Sidin
SF Solid Fuel Burning i ppliances
1 Insulation
I'ela hung Email address D Demolition
5.2 Registered Hone Improvement Contractor(HIC)
j....P�✓ Gt d Ltd Cp.a i FIIC Registration Number Expiration Date -
I IIC Company N:une or HIC Registrant Name
Z. 3CJ < < aL ZT
nd Street Email address
t7tgt'o
City/Town, 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
I, as Owner of the subject property,hereby authorize ",., C't(:2,ol—y 4t�t
to 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: 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.
_IL- A R � 3
I'mit Uwner's o u�at Name(Electronic Signature) Rac
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 Houle Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty bond under %LGL. c. ld_>A. Other important information on the 1-11C Program can be round at
www.n asiA,(m'oca Information on the Construction Supervisor License can be found at uwo.may. :u�L
2. W'hen substantial work is planned,provide the information below:
Turd fluor area(sy. R.) (including garage, finished basement/attics,decks or porch)
ire;; living❑rra(;y. ft) _ __ FLrbictbla room count
Number or tirephtcc;_----------_-- Number of bedrnirmi
Number of bathrooms NnmL+er of halEbaths __---- --
Cvpeothaating ;ytent _ --- _-- NninberufJecks/ porches
I)pe of Cooling ;yalein _... _--. Fiuclosed -- ()pcn
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