37 APPLETON ST - BPA-13-444 INSULATION The Commonwealth of Massachusetts
j CITY OF
Board of Building Regulations and Standards
ALEM
Massachusetts State Building Code, 780 CMR SdMar
Revised Mar 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official U
Building Permit Number: D
Building Official(Print Name) Si ature Date
SECTION 1: SITE INFO ON
1.1 Property Address: 1. sses rs Map&Parcel Numbers
Property, }r�4
1.1a Is this an accepted street?yes X no L 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 Yazd 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:
Zone: Outside Flood Zone?
Public❑ Private❑ — Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERS r
2.1 Owner'of Record:
C y,
n nt) ^ City,State,ZIP
No—.an S eet Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 3% Alteration(s) ❑ I Addition ❑
Demolition ❑ 'Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work': \ i
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building 1. Building Permit Fee: S Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (IfVAC) $ List:
5.Mechanical (Fire Suppression)
$ Total All Fees: $
�� Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 0 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
7O�t\l/1 License Number Expi lion ate
N m of CSL Hofer
List CSL Type(see below)
l 1
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
Restricted 1&2 Family Dwelling
City/Town, a M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) � l t-i HIC Registration Number E ptrati To ate
HIC Company Namb or HIC Registrant Name
e✓
No.and Street Email address
CitylTown,Sta IP 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 Issuance of the building permit.
Signed Affidavit Attached? Yes ..........wo No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Srt�-t�I,as Owner of the subject property,hereby authorize i;Y-- ! L�k(s�
to act on-(ny behalf,in all matters relative
to work authorized by this bull ing permit application.
I1 vu1
Print Owner's Name(Electronic Signature) Date
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 this application is true and accurate to the best of my knowledge and understanding.
Pnnt Owner's or Authorized Agent's Name(Electronic Signature) —� Date
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
3D .mass. og v/oca Information on the Construction Supervisor License can be found at www.mass. ov/dns
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 halfibaths
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"