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The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
4jltrl3 Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This Section For Official Use Only
Building Permit Number: Date Applied: '?I III %-A
Building Official(Print Name) Signature J UUt Daje '
SECTION 1:SITE INFORNIATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
7 Ma Number Parcel Number ^' _I.la Is this an accepted street. yes no P m en
1.3 Zoning Information: 1.4 Property Dimensions: 1
n
_ �
zoning Disuid Pros Use Lot Area(sq h) Frontage(R) Wit
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Z
1.5 Building Setbacks(R) t—C
Front Yard Side Yards Rear Yard D m0
Required Provided Required Provided Required Prided _C
CJ1 C7
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1.6 Water Supply:(M.O.L c.40,§54) 1.7 Flood 'Lone Information: 1.8 Sewage rsposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 O* er'of Rernrd:% r / `�ml l^ O
ICY
N;une riot) City,Stale,ZIP
G-T�aio(-0aa�dann1Q�gQ-@(x� c
No.and Street Telephone Ismail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Altendion(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed bVork':_ t)Q
J
SECTION 4: Es,rIMATF.D CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard Cityfrown Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S
4. Mechanical (I IVAC) $ List:
5. Mechanical (Fire
Su ression) $ Total All Fees: S_
6. Total Project Coat:
Check No. Check AnwunC Cash Amount:
❑ Paid it ' ❑ Outstanding Balance Due:
7 I l (o S�NT TU N •O
1
I
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL"Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu. ft.
R Restricted 1&2 Family Dwelling
City/rown,State,ZIP
M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
'" HIC Registration Number Expiration Date
I IIC Company Name or IiIC Registrant Name
No.and Street Email address
city/'town,State,ZIP Tele hone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(iM.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 .......... 0 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.
Prim Owner's None(Electronic Signanuc) 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 tf' lication is true a accurate to the best of my knowledge and understanding.
lI1
Pnm Owners or Au uftzed 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 Flome 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.ntass.eov/oca Information on the Construction Supervisor License can be found at www.ntass.gov/dns
2. When substantial work is planned,provide the information below:
'rolal 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'
Al
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L?id Y,
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TgYNSE JR.
N . 225 g j
I certify that the proposed structures are to be located as shown,
conform to the Zoning of and
are not in designated Flood Hazard Zone.
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Plan Ov- 233 1 -10
T&M Engineering PLOT PLAN OF LAND IN
Associates,Inc. ��L-e// \? /��' -
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d 83 Pine Street FOR j//ZC; � ( L �
Peabody, MA. 01960(617)535-7328 DATE 11(2 (61 kALE I„=40