4 ALBA AVE - BPA-12-496 SHED Ilia C'ununonweallh of Massachusetts
i� Board of Building b Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Building Permit Application To Construct. Repair. Ren :de r Demolish a
One-or Trvu-Fumilr Dn ellinq
This Section For Official Use nl
Building Permit Number: D e A lied:
1l z
Building Olhcial(Print N;une) , iyta urc
Date
SECTION I:SITE INFORNIATIO
I.1 P pe ty Ad ress: 1.2 Assessors NIap& arc Numbers
I" h�
I.la Is his an accepted street?yes no Map Number I'urccl NuinKr
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed lJsc Lot Area(sy 11) Frontage(II)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided y Provided
Required
1.6 Wate upply:(M.G.I.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage DI posal System:
Public Private❑ Zone: _ Outside Flood Zone?
Check ifes�./ Municipal On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 O�vnert of Record- ^ Wt3
N;une(Print) Uq,State,ZIP
l�ther- 3 ir BSc(5,
r O-),Z4
S r ,I re (�U Cv�v✓
No,and treet Telephone 6nwil Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: IT `
Brief Description of Proposed Work':
t�llpllyGj -- / - V
c
SECTION 4; ESTIMATED CONSTRUCTION COSTS
11cnt Estimated Costs:
(L or and ,Materials) Official Use Only
I. Building g 2 I. Building Permit Fee: S Indicate how fee is determined:
'_. Electrical g ❑Standard Citffown Application Fee
❑Total Project Cost(Item 6)x multiplier _ _ x
1. Plumbing 5 2. Other Fees: S — ----
J. .\lecltanical 111\':\('1 S List__.-_
i
5. .\lechunical (Fire
5 —— -- -
, Su,vession) 'futtl :\II Fees:
I, Total Project Cost: 5 Check No. _--('heck amount: - -- Cash \moue : _
❑Paid in Full Outstanding BuhmCC Due:
S S
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(C'SI.)
License Number---- Fvpiralion Dale
Nano of CSI. I folder -- -- --_
List C'Si.1\pc Isee helmwl
No. :mJ Street _..._____— .I.)PC Description
U I nrestricted I Iluildows up l0 15,1100 cu. It
__ _ It Restricted M2 Fanlil r Dllellill
Geriro,11 Slate.LIP NJ Nlasonry
RC R(x)fing Covering
.---. W'S R'induw and Siding
SF Solid Fucl [)timing Appliances
I "'I'lulion
I cie hone Fnmil address U Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Registration Nunlbcr I\111ratiun Date
I IIC•Compun) Name or I IIC•Registrant Name
No. and Street Email address
City/Town. State,ZIP Tee hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.4 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
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:OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contain in this application is true and accurate to the best of my knowledge and understanding.
Print n•rsnr:\uthuri`c Agent's Name(Elecronic.Sign;nurc) Date
N5'ris:
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 Hume Improvement Contractor(HIC)Program),will M) have access to the arbitration
program or guaranty fund under NI.G.L.c. 1 2A.Other important information on the HIC Program can be found at
oll,l m.l.. -,.t Information on the Construction Supervisor License can be found at rl ,tin
T \Then substantial work is planned,pruv ide the information below:
Total (lour area Isy. R.) _ i including garage. finished basement attics,decks or Porch)
Gross living urea lsy. 11.1 _ - Habilable roust count
Nunlberoflireplaces._-. ._ _._. . . -_— Numherofbedrunms
Number of bathrooms _ _ __-_ Number of hall'haths
j 1)lie of heating s)stein .. ... . _- _ _ Number of decks porches
I 1\Pe of cOgling i�swill Fllclosed _ .. 011e❑ _
1. "ll tal Project Square Footage"nlu) he Substimncd for"I'olal Project Cost"