12 ANDOVER ST - BPA-16-555 ROOF � b �►cl �2i Vo2�A� GI -IJ
The Commonwealth of MassachusdtiiiECEIVED
Board of Building Regulations'an1lufigiR L SE1RV E(,.EIL CITY OF
/1 ® ALEM
Massachusetts State Building Code, 780 CMR SdMar
V ����YY ''yy,, � �� {{�� Revised Mar 2011
Building Permit Application To Construct,Repair,l�n6ro'8te�(yt Aeolis a
One-or Two-Family Dwelling
I This Section For Offic' Use Only
Building Permit Number: 'Date Applied:
1 /3J 1
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Properdre s: � �� r— 1.2 Assessors Map&Parcel Numbers
I.l a Is this ac ec pted street?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 Ow tof etl> 11
, \ {�
Vq IW1G4Tv' ' . `Name(Print" ' I City,Sttate Z
No.and treet elep one Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check al hat apply)'
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Vf Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other ❑ Speci
Brief Description of Proposed Work':
SECTION 4:ESTIMATED CONSTRUCTION CO
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ _ 1. Building Permit Fee: $ Indicate how fee is determined:
El Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier e x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S / 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
IQ-6% License Rom Expi uon ate
Name of CSL Holder v
A!:�-7_� List CSL Type(see below)
No.and S�6eet -r 1 lY/1�6`9l Type , Description
U Unrestricted Buildin s up to 35,000 cu.ft.'�
City/Townl State,ZI M Masonry
cted t&2 Family Dwelling
RC Roofing Covering
WS Window and Siding
r �� SF Solid Fuel Burning Appliances
1
(� I Insulation
Telephone Email address D Demolition
5.2 Regis red Home Improvement Contractor(IIIC)
H egistmtit o r Ex i ion�Date
M CA -Registrant Name
o. tr aV r Email address
Ci /Town,State,Z 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 Issu a of the building permit.
Signed Affidavit Attached? Yes .......... 16 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) ate
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 's a lic ion is true and accurate to the best of my knowledge and understanding.
S
Print O er's r Autia ze g is ame(Electronic Signature) Dat
r 11 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.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.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 of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"