4 ANDOVER ST - BPA-12-35 ROOF HOUSE FRONT I I� The Commonwealth of Massachusetts — --- - - --- --
Q Board of Building Regulations and Standards Cftl OF
of +' Massachusetts State Building Code, 780 CMR SALEM
Revised.t lux 201/
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: to Applied:
tea•, � /3 l
Building 011icial(Print N,une) Signature Date
SECTION l:SITE INFORNIATIO
LI Property Address: 1.2 Assessors Nlap& Parcel Numbers
1.la Is this an accepted street?yes no Map Number Parcel Numtxr
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(tl)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L e.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 ycs❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Mf SaeC C Ark Ag S�tcvim, c� tR70
N;mme(Print) City.Stec— tc
►4 n,,,za.�e� s-r- � 9 �.� - ,Yk- 9ad_�
No.anArect 'telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ .Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTINIATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
_. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 7, Other Fees: S
4. Mechanical IIfVAC) S List:
5. ;Mechanical (Fire $ —.
Suppression) Total All Fees: $_
Check No. Check Amount: Cash AnunutC
G. Totnl Project Cost: $ aa.r{o 0 Paid in Full ❑Outstanding Balance Due: ----
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
_ D --4 3e�r.,r✓.v _ License Numhcr Fspiralion Dale
Name of C'SL Ilulder
List C'SL'rvpe(see bcio%%)__
�—, D 4C- Lq�
No. :mJ Street Type Description
LI Ihvestricled(Buildings no to 35,000 cu. fl.)
�G1 JI.J r/)_ R Restricted 1&2 FamilyDwellin
City/Ibwn.Statc.ZI M Masonry
RC Roofing Covering
W'S Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Tcic hone Entail address D Demolition
5.2 Registered
Aspen `ImproovementContractor(HIC) 11 b8�
2»F: J Q r✓;e�1 S^ - IIIC Registration Number f:.vpiratiun Date
IIIC Company Name or 111 Registrant Name
Si CAA✓ /wF: tin
No. and S ect Lrnbil address
City/Town, State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c. 152.1 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 Issuanc f the building permit.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTORJAPPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize ---�1
to act on my behalf,-in aH ttta rs relative to work authorized by As bull 'n ermit 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 agpljcatioq is true and accurate to the best of my knowledge and understanding.
Print Ot)ner's ur Authorized A cnt's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtairfs a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Hume Improvement Contractor(HIC) Program),will not have access tc the arbitration
program or guaranty fund under M.G.L. c. 1 42A.Other important information on the HIC Program can be found at
y9g nc)�s. ,Oi hea Information on the Construction Supervisor License can be found at t \Nw n:us.,;0�Vp,
2. 11'hen substantial work is planned, provide the information below:
Total floor area(sq. ft.) (including garage, finished basentent,'attics,decks or porch)
Gross living area(sq. 11.) Habitable room count _
Number of fireplaces _ Number of bedrooms
Number of bathrooms _ ...............
Number of halfbaths
1)pe of heating s)stent ________—_-- Number of decks, porches —
-
I)peofcoolings)stem Fnclosed
3. Total Project Square Footage"may be substituted litr-l'olal Project Cost"
l
y The Commonwealth of Massachusetts -- "
i p Board of Building Regulations and Standards CITY OF
.z ;g SALEM
Massachusetts State Building Code. 780 CMR /le1.i.etl (l t.2011
•Lb
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fatnily Dwelling
This Sectio or Of cial Use Only
Building Permit No erg• D e Ap Fed:
thiilding OlTiciar(Print Nmne) mture Date
10
SECT 1: SITE INFORMATION
1.1 Property S �COg ��Address: �(en'IL 1.2 Assessors Map& Parcel Numbers
/ `�
I.I 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 R) Frontage(It)
1.5 Building Setbacks III)
Front Yard Side Yards 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? Municipal ❑ On site disposal system ❑
Check ifes❑
2.1 T=tc& SECTION 2: PROPERTY OWNERSHIP'
/
Noma(Print) C'uy.State.ZIp
, Q) 46nGS Ron C1 (979)
No.and Street "telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work'-:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials) -
I. Building S 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. ,\lechaniad (Fire g -
Su mression) Total All Fees: S
� / �+j C'heck No- Check Amount: __ Cash ,\unxmC
6. Tutal Project Cost: S `7r�� ❑ Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction SupervisorLicense( �CSSL) Z99& —
1 4SA AQ`_.�, License Number Expiration Date
Name orCSI. I lulder
��1 �>� List CSI.1)pe(see below) '..
No. and Street Type Description
U I Inrestricted Buildings up to 35,000 cu. Il.)
(A i V\k U����� I R Restricted l&2 Patnil y Dwellin
OtO rwn.State.ZIP ODO
Mason '..
Rooting Covering
and Sidin91�` —��� n v A Solid Fuel Burning Appliances
' 'Zf m(.1`(Lr-1/IL`.p(�+ �`.C(1,�. InSltlannn
'role hone limail address Demolition
5.2 Registered Home Imprrov�ement Contractor(HIC) 1/' s, 2 0 I i,
o t I IIC Registration Number lispir;uiun Dale
I IIC' 'om ny Nam 11C It•,'s ral Nun c
and street T SMU2od �,Q�I.Cern.
. \ I � . G`R If Fmuil aJdress
Mty/Town, State,Z P `g 'relc hone
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 ........-p 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_Vim, l _ V, .t1S`
to act on my behalf,in all matters relative to work authorized by this building permit application.
2 a ba (E L ,gny r-Vd 4 -- (q
11.�t� ure) I I
Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 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.
-�7—ram (r
Print Other's or Authorized Agent's Naule(Electronic Signature) 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 Home Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 1 42A.Other important information on the HIC Program can be found at
ocn Information on the Construction Supervisor License can be found at lA%N )_us.gu�:yllx
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. It) _ Habitable room count
Number of lireplaces Number of bedrooms
Number of bathrooms _ _ _ _ Number of half baths
1)pe of heating s)Stent ---_ ------ dumber of decks, porches. _---
I,)peofcoolingS)stcnt __----____— Enclosed
i. "Folal Project Square Footage'❑m) be SubSIMINd tor-r0tal Project Cost• O CSC)