35 APPLETON ST - BPA-11-227 REPAIR PORCH I
4
II , The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 C MR, 71"edition OF SALEM
Revised Januurr
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. :/NAY
ne-a tvu-Fumily Dwelling
This ection For Official Use Only
Building Permit Numbe . Date Applied:
Signature: 4 /Q P/(�
Huild' g m Comissi r/Ins uildings Date
SECTION 1: SITE INFORMATION
I.1 Property Address: C 1.2 Assessors Map& Parcel Numbers
I.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information S V 1.4 Property Dimensions:
Q
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(It)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.§54) 1.7 Flood Zone Informatton: 1.8 Sewage Disposal System:
Zone: Outside Flood ZoneT
Public O Private O — Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: yL�,
��n .3S 4 F�'rL Fors f /
XNume(Prinp Address for Service:
tConstruction
Qjt-v, toat&esfan (0�a boo . Ce v 1
ig Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(check aB that apply)
Ne ❑ 1 Existing Building❑ Owner-Occupied Repairs(s) ❑ Alteration(') Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Unib Other ❑ Speciy:
Brief Description of Proposed Work':
e-wlo stipgmrk por-C�L ton l Qewrl rKti ic� ck + k1 c
ctv A V, -Z 1 Z new (�of C6 3av� 2
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated CO513: 011lelal Use Only
Labor and Materials
I. Building S I o ,t)D 1. Building Permit Fee: S Indicate how fee is determined:
�. Electrical s ❑Standard City?own Application Fee
❑Total Project Cost'(Item 6). muIt'Her x
1. Plumbing s / 2. Other Fees: S
4. Mechanical (HVAC) E jp'�. List: 0
S. Mechanical (Fire
Suppression) s / / � Total All Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S o d ❑Paid in Full O Outstanding Balance Due:
i
t
SECTION5: CONSTRUCTION SERVICES
rAd
Construction Supervisor(CSL) CS l D 1-7 � Q 't2 5 2a }Z
License Numb" I:xp(irtttiiun Ilute
er ListC'SL fype(seebelow) v f Descri ion
n� U llntestricteJ u W 35.000 Cu.Ft.
J� cP i'r l R Restricted 1&2 Family Dwellin
Si azure M M Only
jQ -3 1 4- 4 l al Roofing Covering
I cleph me WS I Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 egistered Home Improve at C9otTtor(HIC) b5 O s
)t Oar 4 S Registnuion Number
111C Companyy Name ur tl C Regi (rant ame C`� ,�
1 1 4t11 X;4 o n S �. •w.�a ;AA Y( l Z /L ) h o i l
AdJress K-� 24- 31 Y- Y/ Y) Expiration Dale
Signature t Telepluste
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.f 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 ..........O No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
0OWNER'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.
Si ureofOwner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1 �_)ea ) �� as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application arc We and accurate,to the best of my knowledge and
behalf. qq
. \ Print Name 20
Signature of Owner or Authorized Agent Date
Si under the eains and penalties ofPerjury)
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 M have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I I0.146 and 110.115.respectively.
When substantial work is planned,provide the information below:
Total tloon area(S1. Ft.) (including garage, finished basement/attics,decks or porch)
Grou living area ISq. 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 he substituted for"Tolal Project Cost"