37 APPLETON ST - BPA-13-401 ROOFING ` The Commonwealth of Massachusetts CITY OF
O� e Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One or Two-Family Dwelling
-This Sect on For`Official Use Qnly
Building Permit Number Da[e A lie
Yl
Building Ofticial(Prmt Name) , ig ura `-
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SECTION 1: SITE INF LO
1.1 Property Address: j 1.2 Assessors Map& Parcel Numbers
f Ma Number Parcel Number
1.1 a Is this an accep ed street, yes_ no_ P
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard 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? Municipal El On site disposal system El
Public❑ Private El Check if yes[:]
SECTION 2:;'PROPERTY'O WNERSHIP'` `
21 O neriofRecord:
Name(Print) City,State,ZIP
No. and Street ��� Telephone Email Address
SECTION 3>DESCRIPTION OF PROPOSED W.ORI{' (check all tbat.apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition Cl
Demolition ❑ I Accessory Bldg. ❑ Number of Units_ Other pecify:
Brief Description of Proposed Work :
SECTION 4: ESTI TER CONSTRUCTION,COSTS ,
Estimated Costs: Official Use Only
Item Labor and Materials)_ :�
1. Building $ L Building Permit.Fee $ Indicate how fee s determined:,
Ell Standard City/Town Application Fee
2. Electrical $ ❑Total Project'Cost' (Item 6)x mulhplict ' x
3. Plumbing $ 2 Other Fees. $
4. Mechanical (I-[VAC) $ List
5. Mechanical (Fire Total All Fees: $
Suppression)
Check No. Check Amotmt Cash.amount
6. Total Project Cost: $ /v// 0 Paid in Full ❑ Outstanding Balance.Due
SECTION 5: CONSTRUCTION SERVICES
rSt
ConstructionSupervisor Licensee(CSL) 7�
�r-�p'/�!/v Li—ce-nsUe N�um-ber Expiry ton D
List CSL T pe(see below)
pe, Description
� U Unrestricted(Buildings u to 35,000 cu. ft.
CJ Rzstricted (.g2 FamilyDwzllin
Caty/Town, State,ZIP II N(is my
RC Roofing Covering
WS Window and Siding
Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home
Improvement Contractor IICC)/ /
�x r r"�^�� HIC Registration Number E[xJir on ate
HIC m y Name or HIC Registrant Name
No.arAJtreazl'J _L�7
Email address
City/Town, State, ZIP Telephone u
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 .......... CI- -'No ... Cl
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property, hereby authorize/)-1 Gr)2 k- o/A�
to act on my behalf, in all matters relative to work authorized by this building permit application.
n/�_I r/c 0 IW Al IG i vvt fl- `� 3
Print Owner's Name(Electronic Signature) [e
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
Fenteringe below, I hereby attest under the pains and penalties of perjury that all of the informationplication is true and accurate to the be of my knowledge nd u erstanding.
orized Agent's Name(Electronic Si tahne) tte
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 NI.G.L. c. 142A. Other important information on the HIC Program can be found at
www.mass.gov%oca Information on the Construction Supervisor License can be found at.wwNv.rnass.gov.dps
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 halt/baths
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"