15 ALBION ST - BPA-14-1626 REBUILD STAIRWAY T 15-
The Commonwealth of Massachusetts RECEIVED
Board of Building Regulations and Standards NOMINAL SEWWM
Massachusetts State Building Code,780 CMR SALEM 2011
Building Permit Application To Construct,Repair,Renovate orPART8
One-or Two-Family Dwelling tff
,,This Section For Official Use Only
Building Permit Number: Date Ap I
Building Official(Print Name) Signature �Diae
SECTION 1:SITE INFORMATION,-
1.1 Property Address:,,T E:VT 15 1.2 Assessors Map&Parcel Numbers
J_g AJ0 _F - --1.1a Is this an accepted street?yes_✓ no Map Number Parcel Number
13 Zoning Information: IA P
P_ Gslkt�A-k r-_k 3,7erty Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(it)
Front Yard Side Yards Rem Yard
Required Provided Required:�Pmwdcd Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System;
Public la Private 13 Zone: Outside Flood Zone? Municipal Pk On site disposal system 0
Check ifyesR(
SECTION 2:,PROPFRTY OWNERSHIP'
2.1 Owner'of Record:
J) + Al-No Lt> S AL 4EM PE
Name(Print) City,State,ZIP
I S kL-E51 C)Q 5T 717-?3f-Wal—
We and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction 0 Owner-Occupied 0 JRepairs(s) 0 1 Alteration(s) 0 Addition 0
Demolition 13 Number of Units Other 0 Specify:
Brief Description of Proposed Work': PE13001 SIDAg- _S7A-1"�J , �XTERloa_
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: A
Labor and Materials) y ,Y� Official Use Only�J 1_-�'
1.Building $ 15-00 J..Building Permit Fee:$, Indicate how fee is determined:
2.Electrical $ ,C3 Standard,6ity/Ttrwn Application Fee
11 Total Project Cost'(Item 6)x multiplier
3.Plumbing $ 2. Other Fees!: $
4.Mechanical (HVAC) $ List
5.Mechanical (Fire
Sssion Total All Fees:$'
)
Check- N' o.' �C
- Check Amount: ash Amount:
6.Total Project Cost: $ / -5-00 1i paid inFt111_7'ti' '0 Outstanding Balance Due
:,
M PV LE7D I of is
SECTION 5: CONSTRUCTION SERVICES µ' '
5.1 Construction Supervisor License(CSL)
1
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street " Type,,, Description
U Unrestricted Buildin s up to 35,000 cu.ft.
R Restricted l&2 Family Dwelling
City/Town,State,ZIP M Maso
RC " Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
H
HIC Company Name or HIC Registrant Name IC Registration Number Expiration Date
No.and Street
Email address
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
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:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my ame elow,I here y attest under the pains and penalties of pequry that all of the information
containe n is a is ion is t e a d accurate to the best of my knowledge and understanding.
1JAaJ1 0� l� �- 1
Print Owner' or Autho ' ed Agent Name(Electronic Signature) Date
w a .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 can be found at
mmx og vloca Information on the Construction Supervisor License can be found at www_mass_gov/
2. When substantial work is planned,provide the information below:
Total floor 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"may be substituted for"Total Project Cost"
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