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The Commonwealth of Massachusetts
° Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR 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:
Building Official(Print Name) 'Signature Date
SECTION.1:SITE INFORMATION
1�] Pope fty ddre;s:t �L 1.2 Assessors Map&Parcel Numbers
A t� -
L l 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(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❑
SECTION 2:•PROPERTY OWNERSBIP1
2.1,-°wner of Record: r
ct'ri✓!�J� i'I'1��.2_ Via.//� ; /X
Name(Print) City,Stat ZeCity,Stat IP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Wor`<Z:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:Labor and Materials Official Use Only
1. Building $ 9 J 1. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cosy'(Item 6)x multiplier x
3. Plumbing $ 2.'+!Other Fees: $
4.Mechanical (IIVAC) $ List , "
5.Mechanical (Fire $
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 2-0 ❑Paid in Full ❑Outstanding Balance Due:
+'A4� 1-NAl L Tb U- N NFiElA WE5 --
7 � 3
SECTION 5: CONSTRUCTION SERVICES
5.11 Construction Supervisor License(CSL) OgO7q to L/
Bo r I1.5 -�P/{�j l�j/ License Number t Ex ratio Date
Nagl if
e of CSL Holder / 1
1}f' 0, 6 ny List CSL Type(see below)
No.and Street 9 ,•✓` Type Description
/� U Unrestricted(Buildings u to 35,000 cu.ft.O /
R Restricted 1&2 Family Dwelling
[y/Town, ate,ZIP M Masonry
RC Roofing Coverin
2R�rn� � �N(r WS Window and Siding
SF I Solid Fuel Burning Appliances
gi-3ya 0-6 GOrnc.mT , Avc / I 1
Insulation
Telephone Email address D Demolition
y5.2 Regist d Home Improvement�Coonntractor��-1irIC) , 1 /�, ' 3 (.� -7 7-a3-a nU
W a- 7��r�� "'""m ""e �'y _v HIC Registration Number Expiration Date
HIC C9pan am or HIC Re t9u*Name
1', , BZZF m Caddivw: 0 C-Ornclj r7
No.and Street ' )M D/ q �3 f VQ r-h Email address
QlAaJCi TowT State,Z /,/ D Telephone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation htsurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance f 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
1,as Owner of the subject property,hereby authorize
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 penalties of perjury that all of the information
contained in this a lication is true c to the best my knowledge and understanding.
cam/
Print Owner's or Authorized Agent's a(Electron ignature) 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 hnprovement 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.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.eov/des
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"maybe substituted for"Total Project Cost"
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