8 ALMEDA ST - BPA-14-1252 ADD 3 SEASON, SCREENED PORCH Tom- Iq - I ZZ! 1
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Constnict, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Us Only
Building Permit Number: Date Ap ted:
CA
Building 017icial(Print Name) Signature at y
SECTION 1:SITE INFORMATION N Z
1.1 Pro pperty �/dqd s: ( 1.2 Assessors Map& Parcel Numbers D r—<
Ca
I.I a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: N cj
,p m
yr
Zoning District Proposed Use Lot Area(sy 11) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Y:uds Rear Yard
Required Provided Reyuircd 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'
2.1 Owner'of Record:
5kp/4 KI47Y7_0P05 oYSkl SigiFfy1 W11- d/970
Name(Print) City,Stute,ZIP / /
o J9z8EDf� S'7- 97y7d 9 7/SO euxL� aM��rxtsi ns�r° Q �I�D.Coxx
No.and Street Telephone [.nail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction ❑ 1 Existing Building W 1 Owner-Occupied Re,airs(s) ❑ 1 Alteration(s) ❑. Addition
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed %Vork': ® SE se)
�ol2ef/ oZo r X �O ',
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
I. Building S B Jrpd I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical $ ❑Standard Cityfrown Application Fee
/ �� ❑'total Project Cost'(Item 6)x multiplier x
3. Plumbing $ p 2. Other Fees: S
4. Mechanical (BVAC) S Q List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No.__Check Amount: Cash Amount:
6. 'Fatal Project Cost: S /O, GZOO ❑ Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date 1
Name of CSI.Holder
List CSL'I'ype(see below)
No.and Street Type Description
U Unrestricted(Buildings u to 35,000 cu.ft.)
R Restricted I&2 Family Dwelling
City/Po wn,State,ZIP M Masonry
+ y, RC Roofing Covering
r
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
rele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(H IQ
HIC Registration Number Expiration Date
HIC Company Name or Ii IC Registrant Name
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 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 understanding.
1
r� �cvo51 s�
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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
www.niass.gov/oca Information on the Construction Supervisor License can be found at www.ntass.gov/dps
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. 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 ofcooling system Unclosed Open
3. Total Project Square Footage"may be substituted for"Total Project Cost'