83 ALMEDA ST - BPA-12-173 SHED h 1 File C'umnwnweallh of Massachusetts
I I it i� Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code. 780 CNIR SALEM
Building Permit Application -ro Construct, Repair, Renovate Or Demolish a
One-or Two-Fawilt•Dtrdl(brr
This Section For Official Use Only
Building Permit Number: D e;%pplied:
Bwlding 011icial(Print Munc)
Signature Date
SECTION I:SITE INFORMATION
1.1 Pro erty Add r s: 1.1 Assessors Map di eel Numbers
I.la Is this an accepted street?yes_ no_ blip Numhcr Parcel Numtxr
1.3 Zoning Information: 1.4 Property Dimensions:
Zuning District Proposed U c Lot Area(sq Il) Fromage(II)
1.5 Building Setbacks(R)
Front Yard Side Yards I Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check fifes❑ Municipal ❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
��J
2,Iwnerl of Record: (� c� / y
Nante lPnn��� � U (V ` 01&0 `MCA I c/ � !
City.State,LIP
Z54 I Y —Z y 6 tS
No.and Street Telephone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction ❑ Eristittg Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ I Other ❑ Specify:
Brief Descri non of Pr posed Work-:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and.\laterialsl Official Use Only
1. Building g I. Building Permit Fee: E Indicate how fee is determined:
'. Electrical g ❑Standard City/Town Application Fee
j 7. Plumbing
❑ �Total Project Cost'(Item 6)s multiplier _ x g � — -_----
_. Other Fees: S
4. Mechanical III\':\('1 S List:
5. Mechmlical (Fire S .— _--- --- ---
Suppression) Toted .\II Fces:
�'bTotal Project Cost L'a� Check No. Check Amount: _ Cash :\ino a t;
. g ❑Paid in Full ❑Outstanding Balance Doc:
SECTION 5: ('ONSTRUCTION SERVICES
5.1 ('onstructioo Supcn isur License(C'SL)
I.iccnsc Numhcr ---' �-- Pcpiration D;ue
N:nnc o(l'SI. I folder —
List C'SI.-I'�M'(see beluwl
No. :mJ Street 'I'y Pe Description
U (hresiricted(Il llidin,s up to 35,000 cu. 11..)
__ _ R Restricted I�2 Family Dnellin
C'iwi I own,slate.LIP Iva Masonry
RC Ruolin,C'uverin
.. W:S Window:old Siding
SF Solid Fuel Burning Appliances
I buulutiun
I cic hone [:mail address D Demolition
5.2 Registered Blume Improvement Contractor(IIIC)
IIIC Registration Number Expiration Dute
IIIC'C'ompun) Name or I IIC Registrant Name
No. and Street Email address
City/Town,State,ZIP 'rele hone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 152.1 15C(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 .......... 0 No........... O
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 Nmne(Electronic Signatum) Dale
SECTION 7b:OWNERI 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.
�/�
Printt%%nur's or: w oriieJ Agv l's Nome(EcIrunlc.Sipature) 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 Hunle Improvement Contractor(HIC) Program),will nu have access to the arbitration
program or guaranty fund under I.G.L. c. 112A.Other important information on the HIC Program can be found at
Information on the Construction Supervisor License can be found at ,,o1 ,Ip,
\\'lien substantial work is planned,prov ide the information below:
Total flour area(sq, ft.) (including garage, finished basenlent'attics,decks or porcht
Gross living area Isq. ft.) Habitable room count _
Nuntbcrof lireplaces.__.. ._ _.._. . _ ..._ Numberofbednwms
Numherofbethroolns N'umberofhalfhaths
I\pcol'hcatings)stem .- ._ . _. __ Numherofdecks, porches _
1\pe of GooliI1g s%steltl _ - Fliclosed _ - _.011011
t. ''l oral Project Square Footage- maN he Substituted lir"Total Project Cost"