2 ARTHUR ST - BPA-14-22 INTERIOR REPAIRS The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
(� One- or Two-Faniily DwellingV\ ,
This Section For Official Use Only
Buildmg Permit Number: Dat e
Building Official(Print Name) Sig D '
SECTION :SITE RMATION
l.laroperz Aide, s:S� 1.2 Assessors Map &Parcel Numbers
l.la Is this an accepted street7 yes no 7MapNumber _ Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
e aired Provided Required Provided Required Provided
1.6 W er Supphr:(M.GL a 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone:._ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Z,mer'fofRecor'Pj_
�C.Y�1 � L �
Name(Print) City,State,ZIP
�I b--,Vg I 5co 6AY8--171�n
o.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK"(check all that apply)
New Construction ❑ Existing Building Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief r7�}sc'�tion of Pro osed Wo '
VCR/JIaCO (' ? 1�t'U/1 d, IAA
3 r 0 Y�r S .4- fYLt,l1 �n P i YS'
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
abor and Materials
I.Buildme S aJ!r' eN 1. Building Permit Fee: S Indicate how fee is determined:
2.Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost' (Item 6)x multiplier x
3.Plumbing S 7. Other Fees: S
4.Mechanical (HVAC) S List:
5.Mechanical (Fire S
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S �,j ❑Paid in Full ❑Outstanding Balance Due:
r
SECTION 5: CONSTRUCTION SERVICES
5�.1 Construction Supen4sor`License(CSL)
I\�.✓.4 Ye t•11.7`p� v\ License lNumber !! Expiira6on Date
Name*CSL Holder A
A I 14dl Ygyt� "3y List CSL Type(see below)
No.and Street l� Type Description
Q �N k i �� O�q� U Unrestricted(Buildingsm 35,000 cu.ft.
1 R Restricted 1&2 FatmlDwelling
Delline
City/Tovn,State,ZIP M Masonry_
RC Roofing Coverins
WS Window and Siding
SF Solid Fuel Bumin_¢Appliances
^Y 3 b I Insulation
Telephone Email address D Demolition
5.2 Registered^Home Improvem1ent Contractor(HIC) 1 ,
4 t V �;Ac C egistmtion Number xpt lion Date
HIC om arry Name or Regi ant- ame �.
Ut �VR7 dU W 1V r�lrne�
.and Street r-lt(.�1A Email address
i /Town.State.ZIP / D Telephone
SECTION 6:WORKERS' COD4PENSATION 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 .......... No...........❑
SECTION 7a: OWNE AUTHORIZATION TO BE CO\IPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorized(X'.,p✓�.1
to act on�all matters relative to work authoriz d by this building permit application.
Pint Owner's Name(EI�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 applic 'on is true and accurate to the best of my knowledge and understanding.
X 6-,a� 7-3 - i3
Print Owner's or Authorize gents Name(Electronic Signature) Date
NOTES:
1. An Owner wito 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.maw.gov/oca Information on the Construction Supervisor License can be found at wnvw.mass.gov/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (includine 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"maybe substituted for"Total Project Cost"
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