5 ALBA AVE - BPA-13-326 ROOFING I'lie C omntumvcahh of blassarhusclls
Bo•trd OI'Iuilding Regulations ;utd Sr;utdards Cl I'1' OF
sjti 1 Massachusetts State Building Code. 790 CNIR SALEM
Building Permit ,lpplicutiun TO Construct. Repair, Ilcnov;le Or Dent a R,•ri.1r�/ U'a•:a//
(hm-or rn(t-fi wl,v Uu'rllin.
this Section For Ot iii Use Onl
lluilJing Permit Number. U to Applied; /
lhulJmy Ullicunl(Print Nmnc) Siynaturc
Umc
SECTION It SITE INFORMAT N
LI pert/Address. 1.2 Assessors
is orcel Numbers
i.la Is this an;mce Sad street? es no -lop Numhcr PurcN1 Nunlhcr -
I.J Zoning Informations 1.4 Property Dimensions:
Lining District 11nrpowd llae Lit Area(14 11)
Pmntuye(It)
1.5 BulldingSetbscks(R)
Front Yard Side Yards
Rear Yurd
Reyuircd I'nsviJed RequiredIhuvided
RCt(Ulrcd PNYIJed
1.6 1Vater Supply:(M.G.I.c. yd. §!a) 1.7 Flood Zone Information: 1.lf Sewap Disposal System:
MIMIC O Pr(vute O Zone: _ Outside Flood Zone?
Check II' cs0 Municipd❑ On site disposal s)stem O
2. ones:of Reeordt
SECTION2: PROPERTYOWNERSHIPs
/
N,un Print) 1L City.Slat n 1 ZIP
Nu..mJ Street retr hone
P F.muil Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction O Existing Building❑ OwnerOccupied O Repairs(s) ❑ Alteratlon(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.Cl Nyp3berof Units_
Other O .Spccily;
Grief Description of Proposed Nark':
SECTION 4: E5TIILATED CONSTRUCTION COSTS
Itcnt Estinmled Costs:
ILabur;utd%laterialsl OMCIa1 Use Only
I. Building S I. Building permit Fee: S Indicate how toe is determined:
'. 1:,1wrical S ❑Standard City:Tuwn Application Fee
t I'lunihing S ❑Total Project cost'(Item 6)s multiplier
:. OtherFees:
List:
I I total
r, Total Project Cost i Chcd Vu. _. .__( Itcc1 .1 m�num l',nh \unman:
SOd. ' ❑ P.riJ in Full Oulslanding 11.11.mee Due:
SE('I'IUN S: ('ONSI'RI C. 1aN SF.R16'1 F.S
4.1 C'onstructioo Supen isor l.icenie(CSI.) l;iraliou I)uic
I ic¢roc Nuulhcr
N.uue ul'l'S1. IIuIJer .. -. ..-.. .. .. .. . - I lit Si. I)
Cpc —
.L+q, 1)cscription
.0 Il.l
N„, anJ Slral f l I hlrcstridcJ tllullJin s ti ht 1S,tl110 .
_ R Nmlrioed 1C11:4111il 1)"""Ll
Cit)il',nln,Sl,ac./II' RCItmllin Cntcrin
µ'S Window.uldSidin
-— SF SuliJ Ful: I)urniny Appliunces
I Insulation
N1c hums
fmailaJJnss D Dcnu+liliun
�.2 Rrglstored Ilonte Improvement Contractor IHIC) IIIC' Itcybtr;uiun Numhcf I:%pirollon Umc
III(:Cbmpun) Name or IIIC• t(uyistrunt Nunte Email uJJrvss
No. arid Strccl
'talc hone
Ci !town,Slate ZIP
SECTION 6t WORKERS'COMPENSATION INSURANCE AFFIDAVIT(application.
'G`ation"Fai're to provide
Worken Compensation Insurance affidavit must be completed and s emuled with This a p
this affidavit will result in the denial of the Issuance of the building p
Signed AlpdavitAttached? Yes ..........
No...........O
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 an my behalf,in all matters relative to work authorized by this building permit application.
Dote
Print Utvner's Nwne IEkctrunic Sianuwre)
SECTION 7b:OWNER' OR AUTIIORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the infurmnfiun
contained in his application is true and accurate to the best of my knowledge and understanding.
rint Ue ncf's ur,\ulhorircJ.\punt's unw lliloclrunie Siyn;nurv)
NOTE
\tut�egitr ,h in theaHunts In pruPentantlContr o do lctur(HIC) Program). �llner+have access to thearbitration
lr ctur
Vrt+ytiln or guaran i)litfomtm un on the. C. 1 lrucfian 9upen for Li erase can be round at%tion on the HIC Progrnnt c'ntbel';+wtJ m
�, \\hen substantial Iwrk is ph.....— provide the iniu'rinaluJinglyurage, finished bascntcnf attics.Jocks ar porelu
Raul tiour arcs(sy. R.I . --- Habitable ruwn cuunt
g area 14 IL I .- Ntunher of hcdruunli
(irUii litm ....
� \unlhcrul'tirvplacci ,. ... _ --- Nunlbcrujhalthadts -
\umhcra(hathromos \lunhcrofJccks purOwi
I '\ pc,ltheaung i),Icm (l1'an
I'Ixla,cJ
I\pcof oohng
1 ..1 oq.11 I'f111cc1 S,gtorc I''t�il,lgo Illln he 'kih,11111wd f'or .I'ol.11 'rojC'l C•"I"