21 APPLETON ST - BPA-12-603 FRAME GAS FP UNIT i
:a ---------- TheC'onunonwealthoFMassachuums --
\� i Board of Building Regulations and Standards CITY OF
r �r Massachusetts State Building Code. 780 MR SALEM
V 1 J Building Permit Application 'ro Construct, Repair. Renovate Or Demolish a
Otte-or rut)-Fumih' Du elllugr
Y This Section For Official Use Only
Building Permit Number: Date Ap lied:_
kk4j4cm , LvTtzz4kLvs<A to
Building Official(Print N;unc) Si urc D,le
SECTION I:SITE INF RNIATION
L I Property Address: 1.2 Assessors Nlap& Parcel Numbers
i/ �j»�biYi C J—
I.la Is this an accepted street?yes no Map Number Purcel Number
1.3 Zoning Information: 1.4 Property Dimensions;
Zoning District PruposcJ 11So Lat Area(Sq 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards
Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:( . l.c.q0.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check ifcs❑ Municipal Cl On site disposul system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownerl of Record:
+ kr lty JFfa (i
N;unc(Pm— t) Cily. Imc.Lam'
f4-
Nu.and Succt Telephone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner•Occupied ❑ Repairs(s) ❑ Alteralion(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other Spccily:
Brief Description of Proposed Work': ti
SECTION 4: ESTINIATED CONSTRUCTION COSTS
hem Estimated Costs:
Labormd Materials) WOW Use Only
I. Building S o-o I. Building Permit Fee: S hhdicate how fee is deterntineJ:
2. L'Icctrical S ❑Standard City,Town Application Fee
❑Total Project Cost'(Item 6)x _x
multiplier _
t, (Numbing S P _._
_. Other Fees: S
4. \leclanical ill\'.1<') $ List:
tiuitression) S rotaiA11 Fees: S_
Chak No. ('hak:\m m
ount: Cash \ ount: _
a Total Project Cost: i 2 3 2S, 13 P;iid in Full 0 Outstanding B:d:mce Ouc:
1 {
SECTION 5: CONSI'RliCTION SERVICES
5.1 Construction Supen isor License(C'SIJ
LICCISe Nunlbcr Ivpuaunn uc
Nantc ul'lll. l lnldcr
I iit l'.SI.1)
------------ ----------- --------- "I',pe Description
Na. dnd SlrCel
U I innitricteJ IBuilJin�s ii to 15,IIIItl cu. 11.1
R RcxtricteJ I:C� Tamil Dilcllin
l'ipiloan.State.LIP M Mason
RC' Rtnnin C'urcrin
...—._ R'S Window and Sidin
SF .Solid Fuel Burning,lippllances
I Insulation
I cic hone Entail address D Demolition
5.2 Reg etered Home Improvement Contractor(HIC) b
1-71-0"�L C cr'e J'o'J A�,L' - I IIC I cgisu;aiun Number Expiration Dale
IIIC'('om wt�Na;c or I IIC Itegistmnt Nanic 91
No.and Sufi-ey- )avail address
M417r- n"* n l -?G �J7A o/ `dZT
City/Town.State,ZIP relc hone
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 .......... ❑ No........... O
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 Nwnc(Electronic Signature) Dale
SECTION 7b:OWNER( OR AUTHORIZED AGENT DECLARATION
By entering my naive below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application true and accurate to the best of my knowledge and understanding.
P ' . or nrtiieJ.�genl's Name Ililectnmic Sign;uure) Datc
VOTES:
1. An Owner who obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor
nut registered in the Hume Improvement Contractor(H ICI Program),will M) have access to the arbitration
program ur guaranty runt uodcr\LG.L.c. la?A.Othcr important information on the HIC Program can be lounJ at
v.i Information on the Construction Supervisor License can be found at t+��+�.ni.t>� ^, � Ip.
2, )Then substantial work is planned,provide the infunnaliun below;
Total floor area including ',Jr
linished basenunCattieS.decks ur porch)
Graii living area I iy. tl.l _ - Habitable taunt count
Nuniherullircplaccs __ Number ofbcdrwnis _
Number kit bathrooms _ _ Numbcrufhalfhmhs -
I)pcof heating i)dent . . _ - . N'unlhcr ot'decks, parches . ..
i
I')PC ofcouhng i)ilClll I,IIC1oscd Open .
"11 tal 11roicct Square Footage"ma% he suhstivacd ILr"folal Project Cost"