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BAKERS ISLAND - BUILDING INSPECTION (28) i Q The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF i Massachusetts State Building Code, 780 CMR SALEM \_\1 Revised Mar 2011 \� Building Permit Application To Construct,Repair,Renovate I \1�nJ One-or Two-Family Dwelling This Section For Official Use 961Y Building Permit Number: Date pli Building Official(Print Name) i ature / SECTION 1:SITE O TION 1.1 Pro 1.2 AXsessors Map&Parcel No �i��ers(700 7 6J L l a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning information: 1.4 Property Dimensions: r Zoning District Proposed Use Lot Area(sq It) 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❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ ` SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: .T/1MU'6 CSirl<5 t �all/t1©rri5o�✓ /L1/ 22 ritr c ie N� ©�o � L/ Name(Print) / City,State,ZIP 53 /Aw/2E-41C o5 8 y 7 Gags' �r�rT4 � c1wcI7sr- N No.and Street Telephone Email Address - SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) IQ Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work': SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ 1 ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4.Mechanical (BVAC) $ List: 5.Mechanical (Fire Su $ Total All Fees:$ - Suppression) p Check No.9333 Check Amount: Cash Amount: 6.Total Project Cost: $ I QQO 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 1Construction Supervisor License(CSL) Q f Ba J a Id C2 1s 1,4M rs L s/ �L C- S' License Number Expiration Date Name of CSL Holder � �0J List CSL Type(see below) S3 114w P,&yCe !C Type Description No.and Street 1 / c lG /V U Unrestricted(Buildings u to 35,000 cu.ft. R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry 0,yos—L/ RC Roofing Covering WS Window and Siding /' b p SF Solid Fuel Burning Appliances FjO3'97/ /QSb/ SG / 1S t? cplyl I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number nation Date H[C Company Name or HIC Registrant ' No.and Street Email address Citown,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 1,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,I 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. l /a3/aa/3 Print O is Authorized Agent's Name(Electronic Signature) Date NOTES: I. 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 Rome 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 wy .mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) 660 (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) G"O O 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" 14V EA�4 RH FTC? CUIla,r tlaM j �� LyWood � I%6 Roo-( SNP1,A"41wj Rood /?�a�,rz,s Tots'5, N /p!aTr Lf 6.`. 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