4 ANDOVER ST - BPA-11-900 ROOF / The Commonwealth of Massachusetts
Board of Building Regulations and Stan ards CITY OF
V� Massachusetts State Building Co/aienov
CMR SALEM
Revised Mar 2011
Building Permit Applicatio Construct, Repate Or Demolish a
On -or wo-Family Div
-� This*ctiQn For O cial Use Only
Building Per Number. to Applied:
Building Official(Print N e) Signature ate
SEC N 1:SITE INFORMATION
1.1 Property Address,• 71.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepted street?yes Ito Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq Tt) Frontage(It)
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❑ Private❑ Check if yes[] Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1r,Q �of Re0 i &/
�JJ�� " C �!�riJ S 6.Q2y mt-�---
Name(Print) City.State,ZIP
Y A_Al_�byP 5V75`1--P220
No.and Street Telephone Ennail Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': -
( T&_Pco ovSC
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 00- G 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $
❑Total Project Costs(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (BVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
e�tt,rr m(� Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 6/Ud- 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) O!Z.
fzlvcS License Number Espiration Date
Name of CSL Holder /
List CSL Type(see below) L
No.and Street Type Description
U RestrictdUnrestricted2 Family
(Buildings u el 35,000 cu. ft.) �
Ciittyy'/lToa vvn,State,ZIP R Restricted I&2 Famil Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding •
SF Solid Fuel Burning Appliances
D 1 I Insulation
elc hone Email address D Demolition
5.Aster Home Improvement Contractor(HIC)
2Re Ad,2 �
HI ' Registration Number Expiration Date
HIC Co ,.ne HIC Re istr Name
No�,�d jVeel ^7 p �j�s--'`�/n /, Email address
Ci own, State,ZIP 7, 11 JTelc hone t0
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 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
1,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 penaltie per)ury that all of the information
contained in this application is true and accurate to the best my kn and understanding.
Print Owner's or Authorized Agent's Name(Electronic Sigrilmaw 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.masv.,,ovRwa Information on the Construction Supervisor License can be found at www.mass.noy'dos
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 of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for`Total Project Cost'