16 APPLEBY RD - BPA-14-1737 SIDING I G- l'{
The Commonwealth of Massachusetts INSP��TRECEIL ERVICES
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR SALEM
�. Building Permit Application To Construct, Repair,Renovate Or Demolish a
.' 4e�tOVr�3"
One- or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date pplied:
N f Building Official(Print Name) Signature / Date
- SECTION 1: SITE INFORMATION
1 1 rop ty Addr ss: ers 1.2 As Map &Parcel N
PPIPoy
1.1 a Is this an accepted stree?yes We no Map Number Parcel Number
1.3 jkyi g InformatiFn: 1.4 Property Dimensions:Zoning District (Proposed Use Lot Area(sq ft) Fro tage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required P cd Required P tded Required ovided
1.6 Water pply: (M.G.L c.40,§54) 1.7 Flood a Information: 1.8 Sew isposal System:
Pu Private❑ Zone: _ Outside Flood Zone? icipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
Ot ner'ofR c i11 Sale_ m , Ma 01 (i70
Name(Print) 1 City,State,ZIP
1G R 9V•43D g433 NA
No.and Stleel f Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Atteration(s)X Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief D option of Froposed Work`: / \
1
SECTION 4: ESTIMATED CONSTRUCTION COSTS.
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 20 3S 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ �_ ❑ Standard City/Town Application Fee -
❑Total Project Cost' (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ -
Suppression) Total All Fees:
f?� ��� Check No. Check Amount: Cash Amount:
6. Total Project Cost: $
J ❑Paid in Full ❑ Outstanding Balance Due:
(1 plug o rt S�7 s Homv. trn?2ove. Lt[-t t
SECTIONS: CONSTRUCTION SERVICES
5.1 Con ruction Su ervisorLicense(CSL) 97gi — WudZU16
t6 yer— —.S�a �( V) License Number Expiration Date
Name of CSL �)O
H000lllder
.—1�1 l,A ( List CSL Type(see below)— �
87-7 ok"bson r :" L Type Description
No.a d Street �7
7T U/„ �S CT Q 6 Z--t ( U Unrestricted B Famidinly
s u el ing cu.8.
R Restricted 1&2 Famil Dwelling
City/ n,S dr.,ZIP /'+ M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
7S3 .0452 LSvEC Og3 11 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Corytractor IC) eetr5 J /1 e g D7 IQ& ��JC
Yl) u VeC HIC Registration Number Expiration Date
HIC Comoa me of H C Re oan[N � 1 Rjrku ay vECO83►66)Gknu I /, Cow
�nd Street 8W ' (� U^��7 Emailaddress
W
CiC /To n, State, P OW (Tele honer (�
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 ..........X No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE.COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING, .P/ER,,MITc-
I,as Owner of the subject property,hereby authorizeg6n[s [-4oi ! A —A.�(� o-s J vm
to act on my behalf, in all matters relative tow rk aut rize by this building permit application. _ r5 Pal
t- ri-�-i kos coy) CY at3 ► , z0
Print Owner's Name(Electronic Date
SECTION 7bt 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 application is t e a accurate t he best of m knowledge and understanding.
JL S5v C -A5en 4- C�f31-Z0)4-
Print Owner's or Authori nt's Name(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. 142A. Other important information on the HIC Program can be found at
w Information on the Construction Supervisor License can be f www.mass. og
ww.mass. ov/oca v/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (includi rage, 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
t ---
3. "Total Projec quare Footage"may be substituted for"Total Project Cost"