31 ARBELLA ST - BPA-11-677 EXTERIOR RPRS , . . w
\ � The Commonwealth of Massachusetts
�n � A Board of Building Regulations and Standazds CIT1'
�i\� � Massachusetts State Building Code,780 CMR,7"'edition OF SALEM
\ Revised January
� Building Permit Application To Construct,Repair, Renovate Or Demolish a I, 2008
-or wo- ily Dwelling
i e 'on or Official Use Only
Building Permit N ber: Date Applied: ' �
Signature: 3�J��
Buildin Commissioned Ins c r of Buildings Date �-
SECTION l:SITE INFORMATION
1.1 Property�`ddress: 1.2 Assessors Map&Parcel Numbers :
-- .,.�.,�..� '� / /f.+'SC�l.t s'� �
1.1 a Is this an accepted s[reet?yes_ no Map Number Parcel Number
1.3 Zooing Information: 1.4 Property Dimensious:
Zoning District Proposed Use _ Lot Area(sq ft) FronTage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Reaz Yard
Requ'ved Provided Required Provided Required Provided
1.6 Wate/r Supply:(M.G.L c.40,§54) 1.7 Flood Zone Informafioo: 1.8 Sewage/Dy'sposal System:
Public B" Private❑ Zone: _ Outside Flood Zone? Municipal H On site disposal system ❑
Check if yes�
SECTION 2: PROPERTY OWNERSHIP'
2. O�'ner of Reco�/rdy-�� �� > (� /
JY/G/OP� �G«/G//"a-- L /�AG�v.«v �Sf" cJGi./CM /+�
ame rint Address for Service: �
� ,a �K/- �2�J` U��(�
� Sig ure Telephone
SECTION 3:DESCRIPT OF PROPOSED WORKZ(check all that appiy)
New Construction❑ Existing Building � Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑
Demolition Accessory Bldg.❑ Number of Units� Other ❑ Specify:
BriefDes/cri�ptionofProposedWorl�: ���y �,�>c4» ... Si� w.� �4S
P�'m^L/ L l�l��,/Y�4vas G^/ y w'.'.�'\ ��co1'S �/�C
SECfION 4: ESTIMATED CONSTRUCTION COSTS
ltem Estimated Cosu: Offcial Use Only
abor and Materials
1.Building $ . 1- Building Permit Fee:$ Indicate how fee is deternilned:
2.Electrical $ � Standard City/Town Application Fee
❑Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Su ression
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ Ga � O� ❑paid in Full ❑Outstanding Balance Due:
/
: . �
SECTION 5: CONSTRUCTION SERVICES
51 icensed Construction Supervisor(CSL) �U 3 4�� ����o ��
��,/ �jce��G�+,` License Number .Expiration Date
�-
Name of CSL-Aolder n p List CSL Type(see below)
!O Scw+.�+."-� /�'L i.tn.`�� /iCtiri� «A U //��
Add T Descri tion
� Unrestricted u to 35,000 Cu.Ft.
� Restricted 1&2 Famil Dwellin
�gnature � M Maso Onl
3�i-9s�3- ��s/ RC ResidentialRooFin Coverin
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Bumin A liance Installation
D Residential Demolifion
5.2 Reg;�ste�Homp�Inlpgovemen�/�ontractor(HIC7 JG S y7�sl
/�Gr'fl_v: if.,�-/�,�c�
H'IC Company N e or HIC Registrant Name Regisaation Number
a �•�,,' /.-c �., f �� � olg� PJ�l��3�y�/Z
Ad
��/- �s3- d li�r/ Expiration Date
�gnature 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 Issuan f the building permit.
SigneA Affidavit Attached? Yes .......... No...........❑
SECTION 7a:OWIYER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CON"I'RACTOR APPLIES FOR BUILDING PERMII'
I, /N/CGIG. ��G y i� as Owner of the subjec[property hereby
� authorize a �w �r- _ to act on my behalf,in all matters �
relative to work authorized by this building pertnit application. ,
�� �z3�2�/�i '
Si atureofOwner Date I,
SECTION 7b:OWNER'OR AUTHORiZED AGENT DECLARATION I
I, � w '7u`�`'" ,as Owner or Authorized Agent hereby declare ��
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and '
behalf. � y� ,/ `
w /��t/Jo�-
Prin
v 3/a�/i�
� ignature of Owner or Au orized Agent Date
� Si ed under the ains and nalties of 'u
NOTES:
' I. M Owner who obtains a building pertnit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Lnprovement ConVactor(HIC)Program),will not have access to the azbitration
� program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Consdvdion Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively.
2. When substan[ial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basementlattics,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/porehes
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project CosP'
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