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X\ The Commonwealth of Massachusetts
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Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Nlnr 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For Official Use Only
Building Permit Number:
Building Official(Print Name). ature D
SECTION U SITE INFORMIATION
LI Property Address: L2 Assessors Mlap& Parcel Numbers
.0:a Q�.G�ii iu."a ,uy,
I.la 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 R) Frontage(It)
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 M-"� Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION2: PROPERTY OWNERSHIP,
2.1 Owner of Record:_ n
�A-N wti- t LDS 1 J S Cc��w (//�J
me(Print) 14 gAW /yJ City,State,ZIP
No. and Street Telephone C•mail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ I Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work'-:
W! (,nNf 'f✓vii�i`n�v 6 S r-Y Gaff. '1'li Ntr..i �- citl
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:
-Labor and Materials Official Use Only
1. Building S I. Building Permit Fee:$ Indicate how fee is determined:
�. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $
4.Mechanical (HVAC) S List:_
5. Mechanical (Fire $
Suppression) Total All Fees:$
Check No, Check Amount: Cash Amount:_
6. 'ruCd Project Cost: $ 0 Paid in Full 11 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES J
5.1 Construction Supervisor License(CSL)
License Number Expiration Dale
Name of CSL Holder
List CSL Type(see below)
No.and Street Type -Description
U Unrestricted(Buildings up to 35,000 cu. 11.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Compa ty Name or HIC Registrant Name
No.and Street Email address
i /Tot 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 FO/R/BUILDING PERMIT
1,as Owner of the subject property,hereby author*
t9 act on my behalf, in all matters relative rVQ0QK authorized by this building permit application.
/3 /3
Print Owner's Name(Electronic Signature)'yDate
SECTION 7b:OWNEW ORAUTHORIZED AGENT DECLARATION-
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
con med in this application is true and ac rat tot a best o my knowledge and understanding.
Print Owner's or 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 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.eov'oca Information on the Construction Supervisor License can be round at www.mass.uov./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"