13 ALBION ST - BPA-10-257 ROOFING ' 1
The Commonwealth of Massachusetts CITY
Board of Building Regulations and Standards
^` Massachusetts State Building Code,780 CMR, 7th edition OF SALEM
Revised January
\ _ Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008
�( Jl One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied: `
Signature: I`
b 2 1 • Q
ii
Building mmisswner ]ns ctor of Buildings Date-
SECTION 1:SITE INFORMATION
1.1 Pro{�erty Address: 1.2 Assessors Map&Parcel Numbers
1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
CZ\ 1SAQVV% • 039 axc,ne5
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 Wate/r.Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage DD''sposaI System:
Publicv Private❑ Zone: _ Outside Flood Zone? Municipal L9'On site disposal system ❑
Check ifyesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
,]K2xw&C \rs hind S--ts� SC6Q QACC) IM(�
tlName int) Address for Service: �7
I` I "/ 7 7 UU, 1/Gl
gig,a J T epl
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construct n ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) D.If Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work 2: — -
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (FfVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:.
6.Total Project Cost: �% 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
Jn � 6
/. U?-Ch / License Number Exp on ate
Ninfic of CSL-Hol r 6 �' "}
�L ,� � t -- tst CSL Type(see below)--acL
Addres Type Description
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 FamilyDwelling
Signature M Masonry Only
7 J RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Renrs `titered Ho Improvy/¢_ment Contractor(HIC) /��
( ^GiJ /'I�+Oh u S
HIC Company Name or'HIC Registrant N e // Registr ion Number
Address
xpimtio ate
Signature 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 Issuanc 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, 2c1 -4-r,Y \D as Owner of the subject property hereby
authorize CC>,1)SAIN(:Yi ( to act on my behalf,in all matters
relative to work authorized b is building permit application.
28 0
Sign of Owner Date
S ION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I, as Owner or Authorized Agent hereby declare
that the statements and information on&foregoing application are true and accurate,to the best of my knowledge and
behalf.
Pri N e
G Z o
Si ature of Owner or A h i ed Agent Date
ed under the pains and a ties of r'u -
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 Improvement 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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below: _
Total floors area(Sq.Ft.) (including garage,finished basementlattics,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"