BPA-13-30 MISC. EXTERIOR REPAIRS a --- I he C onunun\eculth ul ibl:u,achuSclls
Board of luilding R"tilaliuns and Standards CI I'V OF
s kf;1SSac1Iusctts State BuildingCode. 7SB C NIR SALEM
'L�•' /fdrieri/ 161r'U//
Building Permit Appliruiun To Construct. Repair. Renovate Or Demolish a
One-or Atli-funnll' Un'cllin.V
This Section For Olflcial Use Oil
Building Permit Number: Do[ Appppliicil: _
Iludding Utlicial(Print N.,ne) Signature i1cJ
SECTION I: SITE INFORMATION
L1 P�prrty Mdress: 1.2 Assessors flap S Parcel Numbers
d� 5-7
I.la Is this an accepted street? es no Map Numhcr Parcel Number
I,J Zoning Information: 1.4 Property Dimensions:
Luring District Proposed Else but Area(sq II) Frontage(ll)
1.5 Building Setbacks(R)
Front Yard Situ Yards Rear Yard
Required 11ruvided Required Provided Required Provided
1.6 Water Supply:(M.O.I.c.Jo,§s4) 1.7 Flood Zone Informations I.lI Sewage Disposal System:
Public❑ Prls ate O Zone; _ Outside Flood-Luna? Munici d O On site disposal Check IY 'cr0 P s)stem O
SECTION1: PROPERTY OWNERSHIP'
2.1 Ownerm of Record:
N;una(Pnm) Uq•,State.ZIP
Z 5�
Nu.and Strict relephone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction a 1 E.risting Building O Osvner•Occupied ❑ 1 Repairs(s) O Alleratlon(s) O I Addition 0
Demolition 0 Accessory Bldg.O Number of Units_ Other O Speciry:
Brief Description of Proposed Work':
.�17/SG�s�/La2itr�9r�� x�--,Piot2 E�l.�{as2c T�—!o4/ .Si.�lir�i
SECTION J: ESTIMATED CONSTRUCTION COSTS
Itcnt Estimated Costs:
l.ahur and %laterials) Official Use Only
I. Building i I. Building Permit Fee: S Indicate how lee is determined:
2. I:'IccVical i ❑Standard Ciry•Town Application Fee
1
i
❑Total Project Cost'l item 6)a multiplier _ _ c I'lunihing _
_. Other Fees: S_
J. \1cch.mical ill\ \(') i List:
\Icch.utical I ve — -- -- — _--- -- -- ..._
�uIvessianl i fatal .\Il Fces: i
n l'otal Project Cost: ) ��p/�dv ('hrsk \'o. --_-_(.Beck A"It"Iue
/p ❑ Rmid in Full 0 Ootslanding II.J.mcc Due:t0 (
on /y'uc �
SI:( I ION 5! ONS I WI,(-riON SERVI( F5
---1—
A Coni I ruc I io[I Sul)cr%i%or I.icense S L) Z-5�—e 410,0 Z(,
5
1 vvo,e
oe*x
,irictc,J M2 I
L io"l omi. S1,11C./11' M
Ill' H,alin Cal Grin -
%A S Window Uld.swidol57 ll
ar AM��- V05K�744O SF solid Fuel Burning Appliances
f5-6-7
Folail D Don"I'll in
I'elc hone
.d,.r,,..,I I irl
411 Registered flume Impru%erneul Contractor(IIIC)
l(cilig,;,tion N..ohr r\piration Wtv
111 ('tilopin) Name or I IIC liegi.itrant Njing
[:Irluil iddruis
No. and S"wil
one
City/Town. State ZIP reic
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 issuance of the building permit.
Signed Affidavit Attached? Yes .......... a No...........a
- �TO BE COMPLETED NVH EN
SECTION lull :a- 01-1-NERAUTHORIZATION
OWNER'S AGENT ORCONTRACTOR 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.
Date
c Signature)
SECT OWNER'OR AUTIIORIZED AGENT DECLARATION
By entering illy 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,
Dale
NOTES:Nam:
I. .\n Owner %%hocbtainsabuilding permit to do his her own %%ork,or an owner who hires an unregistered cuiitrulor
I liot registered'in'the Home rictor I H IC) Program),will!Up have access to the arbitration
o niallon on the HIC Program can be 11ound at
u':mpro%eJJ'C"'CU"'
program ur guaranty lolld &r.M.G.L. c, 142.v other Iiiponant inlbr be found at,, P,
" "' ' 'l_'"
I Information on the Construction Supervisor License can
2. lien substantial work pl;o1rej.proNije the itilluriontion below:
11 1 including garage, finished b3sementaiii". decks or pordi)
roo flour area(1+ 11 1 lf�ibilahld rot)"'count
c.'". I""'o ",a I'd
roii li% lig .1rea I 5q. it.) \L1111her ot'lledrotims
\umbvr ol hall hall"
Niollher of hathroullis \11111her ofdv�ki porOies
I '%'lelo 01wil
I
1 ,IlhJllll thI ior "1'ot.il Proj"l (*o,I