53 APPLETON ST - BPA-16-1300 KITCHEN RENO The Commonwealth of Massachusetts , i V y
Board of Building Regulations and St2iia ll !3J f $t 1" CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 1011
Building Permit Application To Construct,Repair,Reid&kht%Q_Vr 1)6SRt SQ d
One-or Two-Family Dwelling
_ This Section For Official Use Only
Building Permit Number: :i Date Applied:
Building Official(Print Name) Signature Date
f SECTION 1: SITE INFORMATION
1 Property Address: 1.2 Assessors Map&Parcel Numbers
Lla Is this an accepted street?yes no Map 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 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:
Public ^ Zone: _ Outside Flood Zone? e/
Private❑ Check if yes❑ Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'gtReco d: 1
N_ aa.dC, - r S3 /��n�r�iN �f S'G�i°Hi /17if O/970
Name(Print) City, PP
53 4, (,C-1,nr s'f 78/-9S'3-3360 9t+/A/7k5,J2 �'auaC6M
No.and eet Telephone I Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building I Owner-Occupied Repairs(s) ❑ 1 Alteration(s)X I Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ I Other 13,Specify:
Brief Description%Proposed World: / <' r-el e - 4e, I-AlP lau
iN 2. c C P 4N ,{iw// 6n
/l f c r // Y' ^f 6 G
S CTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1.Building $3.5 0 , Oo 1. Building Permit Fee:$ ' Indicate how fee is determined:
13 Standard City/Town Application Fee
2.Electrical S '1 0 U ,U o p Total Project Cost'(Item 6)x multiplier x ..
3.Plumbing $ 00 ,0 0 2. Other Fees: $ r
4.Mechanical (ffVAC) $ List:
5.Mechanical (Fire $ --S ssion Total All Fees: $
u re
Check No." Check Amount: Cash Amounti
6.Total Project Cost: $ N q00 ,OCR ❑Paid in Full ❑Outstanding Balance Due:
d> Cahv+/O, — i l a rnn c .
J
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
o
'�-A / yae�dA✓a/� sy
E �rnti n Date
Name of CSL Holder
6 : d O o ' j - , List CSL Type(see below)
No.and Street /� Type Description
katt �f n O/�� 9 Unrestricted(Buildings u to 35,000 cu.ft.
�' /T to R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP Masonry
RC Roofmg Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
V? 77/ 6 klVlocg7�e�vmrlirl ,,� I Insulation
Telephone Email address D Demolition
5.2 Registered Hom01
Improveent C tractor(HIC) 1�3� N
i I I1m
C 6 n 1 C HIC Registration Number Expvanon ate
HI Co pony Name or H Registrant Name / � //
�Nc>_a r� /J/1'IaG%`7P@f0�1C�ti/V�T
No. d Street M q / n p�+ Email address
Ci� State,ZIP Tele hone
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 lssuancE of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
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 [ Ee 1 y L � G c b n 141 a I J
to act on my behalf,in all matters relative to work authorized by this building permit application.
mi e aNk 4'( � 1-14tA s ,<t o y ao l
Print Owner's Name(Electronic Signature) Date
SECTION 7b: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 true and acl1�/�trate to the best of my knowledge and understanding.i Yodc- fCogc P wr"1100&
Print 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
www.massgov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dpss
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 half/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"