BAKERS ISLAND - BUILDING INSPECTION (17) 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-Family Dwelling
This Section For Official Use Only
Building Permit Number: D te Applied:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Pare umbers
DRY S Ssuwn �--WlS
I.l a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Pr pergt 7Ditmensions:I'S DSO .
Zoning District - Proposed Use Lot Area - 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❑ PrivateI Zone: _ Outside Flood Zone? Municipal❑ On site disposal system
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner[of Record: wiz5� N1iJ"-'134/L"lt /1'IA, 01��5
1Zt�ss� STi 1.1=5
Name(Print) City,State,ZIP
Z'14 M+jpLt S ST 0--610-4oy9
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building Owner-Occupied ❑ Repairs(s) '14 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units I I Other ❑ Specify:
Brief Description of Proposed Work': AKPLAC$ );bkc-14
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ S goo, e= 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ b -2. Other Fees: $
4.Mechanical (HVAC) $ d List:
5.Mechanical (Fire $
Su ression) Total All Fees: $
00 Check No. Check Amount: Cash Amount:
6. Total Project Cost: $
S(tjf�• ❑ Paid in Full ❑ Outstanding Balance Due:
Y7 fP
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS—I O I SID
1�NSst—u— License Number E pir ion Date
Name of CSL Holder
-t LLtt List CSL Type(see below)
aLt MIfl17 YL J LT Type Description
No.and Street
U Unrestricted(Buildings up to 35,000 cu.ft.)
� gT Ivlgl�RiidLs i R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
b��Sib^`l0` 11t£5�ldn�% rT71in9A/utf>~af I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State,ZIP 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 .......... ❑ 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
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 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.
TVVe(,XL-L- 4, sf;Ls y- 19,-13
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.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.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 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"
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h . Y CITY OF &U ENf, i us.,ICHUSETTS
Bt:ILONG,DEP.SR'I ONT
` 120 Cf/.�SNLYGTON STREE FL T, 3" OOR
TEL (978) 745-9595
KIN 10ERLBY DRISCOLL F+x(978) 7-W-9346
AUYOR TI[wrA3 Sr.PIERRB
M%Ecrca OF Pl:ttuc PROPERTY/SVILOLYG COS131ISSIO,NER
Construction Debris Disposal Aftldavit
(required for all demolition and renovation work)
In accordance wi th the sixth edition of the State Building Code, 730 C&IR section l l 1.5
Debris, and the provisions of rbIGL c 40, S 54;
Building Permit 4 is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal racility as defined by 1WGL c
l 11, S I50A.
The debris will be transported by:
(name urttaulur)
The debris will be disposed of in
(name of racility)
Gun�C4-rar."
(.tJJres.t of taaili y)
Signature ui,y¢-mit apptican