8R ALLEN ST - BPA-11-367 NEW REAR DOOR The Commonwealth of Massachusetts
1 Board ul'Building Regulations and Standards CITY
Massachusetts State Building Code. 780 C'MR. 7'edition OF SALEM Rcrrirt n•
H 2WAYuilJing Permit Application To Construct, Rrpair, Renovate Or Demolish a 1. 1rx6Y
One- -Fumdy Dwelling
This Section ForOflici nl
Building Permit Number. to Applied: U
Signature: I /
Buildin toned In tut Buildings fate �—
SECTION 1:SITE INFORMATION
1.1 Mira Address:� ee 1.2 Assessors Map dt Parcel Numben
I.to b this an acce !ed street?yes no Map Number Parcel Number
I Zoning loformatlon: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Fronmge(11)
1.5 Building Setbeclts(R)
From Yard Side Yards Rev 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 O Zone: _ Outside if es0 Flood Zoro7 Munieipsin CheckOn site disposal system O
SECTION 2: PROPERTY OWNERSHIP#
I
wner#of Recor -
4 � � �1 l o r <!Skf ee-,1-
1P ' t Address61r?S9,Service: t ' -loam
t �- (I- I `K e-[
ure Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
onstruction O Existing Building IN[ Owner-Occupied jlt Repairs(s) Alleration(s) O Addition O
lition O Accessory Bldg.O Numberof Units Other O Specify:
escription of Proposed Work' r e0t -SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OtRcial Use Only
Labor and Materialsing S 1. Building Permit Fee: S Indicate how fee is determined:
O Standard City/Town Application Fee
ical S O Total Project Costs(Item 6)x multiplier x
bing S 2. Other Fees: S
anical (HVAC) Is List:
3. Mechanical (Fire S
Suppression) Total All Fees: S
/ •� ` Check No. _Check Amount: Cash Amount:
6. Total Project Cost: S v 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed
: ' Construction Supervisor. CSL/)
Po C=,20 � lJecrue Num r �IipJin_ataiun(Do?_un_te
Nm lS!11 Ider I.ist CSL rype Isce below)
� r Uescri i
Lo U Unrestricted to 35.000 Cu.Ft.
Restricted l&2 Family Dwelling
RC Reiidential 0.aulin Covering
relephsute WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Reiidential Demolition
6.2 glittered H oqe improvement C,eptrue r IHI )
IIIC m Nl. �rSN ( O ryn Re—visretiort Number
yt me
,nlr ll� q"/ .Y1 ".��1 .piration Date
Siynyure 'relephunt
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. Ill. f 2!C(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..........O No...........O
SECTION 7n: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.
immaure of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1 as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application we true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Sivised under the Pains andpenalties of 'u
NOTES:
[L.—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 sMW have access to the arbitration
program or guaranty fund under M.G.L.c. 1 42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 IO.R6 and I IOAS. respectively.
�. When substantial work is planned,provide the information below:
Total (loon area(Sq. Fl.) (including garage, finished basement/anics,decks or porch)
LNumber
ving area(Sq.Ff.) Habitable room count
of fireplaces Number of bedrooms
of bathrooms Number of half/baths
healing system Number of decks/porches
cooling system Enclosed Open
tal Project Square Footage"maybe substituted for"Total Project Cost"
MORTGAGE INSPECTION
BAY STATE SURVEYING ASSOCIATES INC.
n100�CUUMMINGS CENTER, SUITE#316J, SEVERLY,MA., 01915
LOCATION\t S..�I LU 1 MA NOTM.
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eompueo wth the is IOW zoning eetttatd[s at the tone at be used to estsbllsh property tlnst.
eonsvuetlon or Is eiem t p irom viola
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under Mace G.L Title VIt Chapter 40.a e•�fon T
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