81 ALMEDA ST WEST - BPA-13-837 ROOF The Coin momvealth of Massachusetts
�- Board of Building Regulations and Standards CITY OF
SALENI
Massachusetts State Building Code, 780 CM Revised Mar dMar
1 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dhvelling
Chis Section For Official Use Only
Building Permit Number:.; Date Applie
77
Building Official(Print Name) .:Signature Date
SECTION L SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& P el Numbers
P l RLI►1t!/JR ST GJEST
1,l a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(R)
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:
Zone: _ Outside Flood Zone?
Public itd' Private❑ Check Municipalif es'O❑ Municipal❑ On site disposal system ❑
SECTION2:; PROPERTYWNERSIIIFj- ':
2.1 Ownert of ReFord:
h?R2�AA) I-An sqt tplt Mt '01g96
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 ❑ 1 Repairs(s) &' Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work' S"t72y0 rfiP4#J d SO/%i/T R,4,, 5 / hY' /e.0— 'G/ J4 SN C4iV
roe Gt rT 6T IA&
a/� ra F dln/t tfl4AXaES aj AM5
SECTION 4: ESTUNIATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
v.
I. Building S L Building Permit Fee: S indicate how fee is determined:
❑ Standard City/town Application Fee
2. Electrical i ❑ r
Cotal Ptolect Cost (Item 6)x rrrultiplier. x
3. Plumbing S 2 Other Fees:'S
4. Mechanical (11VAC) S List
5. Mcch:mical (Fire $
Su t ression) Cotal:\ll Fees:S
— — Check No. Check Amount. Cash Amount.
6. 'Total Project ['ust ) Q P _
1 60, 0 Pau! in Full Cl Outstanding Balance Dua:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSI,)
Z4 _ Licens z umbc E.e mti n Uatc
Name of CSL I!alder
21 ,�� �nt`�.�,, List CSL Type(see below)
( J W ` IM— Type Description
No. and Street
—_�E ,/' Q/ O U Unrestricted 6uilJin s u to 35,000 cu. Il.
7 (pO R Restricted 19c2 Famil Dwellin
City/Town, State, ZIP M Masonr
Rootin C, ,rim
Window and Sidin>
SF Solid FOCI Burning Appliances
Insulation
"Tole hone F / Email address Demolition
5.2 Registered Hone Improvement Contractor(TIIC) Ia/ 7
---R"&f6A ?(.1't' )IfyTfJlL�Cl�S HIC Registration Number E pira on Date
I TIC Company Name or IIC Registrant Name
nrufSer 7
No. alv Street
1"A4 &y,k6 /_ Email address
City/Town,State, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. e. 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
t, 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: 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 IZ
ate to the bes of my knowledge and understanding51
Print Owner's or Authorized Agcnt's Namc(E •ctrunic Signn irc tie
NOTES:
I. :\n Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Horne Improvement Contractor(HIC) Program), will not have access to the arbitration
progr:un or guaranty fund under M.G.L. c. 142A. Other important information on the IIIC Program can be found at
www.masS."0v/oca Information on the Construction Supervisor License can be found at tvwtv.mass.eov dL
�. When substantial work is planned,provide the information below:
Total floor area(sq. It.) _ _ (including garage, finished basement/attics, decks or porch)
tiros, living area(sq. tt.) _ Habitable room count
Nimtber of tit eplaccs._---- Number of bcdronms --_--- _
Number of bathrooitts _- Number of halbbaths --
fvpu of heating system Nwnber of darks/porches
PVpettfcoolingiyitcm--------_---._-- Enclosed tlpun
1. "Total Project S(1uaro Foom C' utay be subitiuncd tk)r"1'ut.tl [It uitct Coit'.