3 ALLEN ST - BPA-13-514 RESIDE RIGHT SIDE OF HOME The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CM Revised Mar SALEMdMar
!( 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Divelling
Chis Section For`O. icial Use Only
Building Permit Number: D t pl'
!� 8
wilding Official(Print Name) . Date.- -
SECTION 1: SITE IN {
1.1 Property Address: l.2 Assessors Map & arce N bers
J 3 Al,LMI %T . /
1.1a Is this an accepted street? yes no Map Number P rc l'Number
1.3 Zoning Information: 1.4 Property Dimensia
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 OWNERSHIP:
r
2.1 Owner'of Record: /
i/ AAAr CC t Ck'+0
Name(Print) City,State,ZIP
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK" check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑Z Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': igtGKT St De OF HOUSE ,
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
item Official Use Only.
Labor and Materials
1. Building S 1. Building PerrnitFee: S Indicate how fee is'determined:
Electrical $ ❑ Standard City/Down Application Fee
2. ❑ Total Project Cost'_(Item(5)x multiplier x
3. Plumbing S 2. Other Fees: S
1. Mechanical (FIVAC) S List_
5. Mechanical (Fire $
Su t ression) Total All Fees: S
Check No. Check Amount: Cash Amount
6. Total Project Cost: 8
l/�Z000 . 00 ❑ Paid in Full El Outstanding 13nl;mce Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL)
License Number Expiration Date
Name of CSL Ifoldzr
List CSL'Type(see bzlow)
No. and Street — Type .: - - Description
U Unrestricted(Buildings up to 35,000 cu. It.
R Restricted 1&2 Family Dwelling
City/Town, State, ZIP Ni Masonry
RC Roofing Covcrin
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Fclz hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
FI[C Registration Number Expiration Date
HIC Company Name or FIIC Registrant Name
No.and Street Email address
City/Town, State, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (tM.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
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 7h: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understandin
Print wncr's or r\uth on zed A.ent's Name El(Electronic Signature) Date
NOTES:
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 Home Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the FIIC Program can be found at
www.massgov/ocu Information on the Construction Supervisor License can be found at www.mass.eovhlL
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. (1.) Habitable room count
Number of fit eplaccs_ Numberotbedrooms .
Number of bathrooms Number of half/baths _
Type of heating system -- __—_ Number of decks/ porches
I'ype of cooling system _ Enclosed _ ---Open _
..3. "FotA Projoct Squm'c Footage" zany be sub_ntutcd fist_ I wA Projzct Cost" _---- ----_--_--