1 AMANDA WAY - B-14-30 NEW DECKS 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 Construct, Repair, Renovate Or Demolish a
One or Two-Family Dwelling
- This Section For Official Use Only
Building Permit Number: Dat Applied:
Building Official(Print Name) Signatur Date
SECTION l:SITE INFORLbWN
1.1 Property Address: 1.2 AssessorsAap& Parcel Numbers
1.1a Is this an accepted s eet?yes_ no Map Number Parcel Number
1.3 Zoning Information: - 1.4 Property Dimensions:
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'
2.1 Owner'of Record:
)ail le/ Inr✓�Grtlyc�h tj 1111uh J/j�00A /x/970
Name(Print) City,State,ZI
f ,4vyrandu Na,r697�Syy Dyd Dan /. l'i11Wan1?J'VAamvLrnrn
No.and Street I - Telephone Email Address T
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction Existing Building❑ -Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition it
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': 1 Zt Clert It U, buz pally
W 1
5.
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building .$. ZJ�` 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Su ression
- - Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ v`(�Qd, Qv 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5A. Construction Supervisor License(CSL)
,. . . ... : - License Number Expiration Date
Name of CSL Holder .:
List CSL Type(see below)
No.andStreet - Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted I&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
I I Insulation
Telephone Email address _ D Demolition
-- ' 5.2 Registered Home Improvement Contractor(HIC) -
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /Town, State,ZIP - Tele hone
SECTION 6:WORKERS' COMPENSATIONINSURANCEAFFIDAVIT(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: 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 understanding. -
J onwlzand6l7Ab 4+sSaffiUak1 Jup I Is
Print Owner's or Authorized Agent's Name(Electronic,Signature) ate -
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 ImprovementContractor(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.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
2. When substantial work is planned,provide the information below:
Totalfloor 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 of cooling system Enclosed : Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"