18 BOARDMAN ST - BPA-14-609 RPR 2ND FL REAR PORCH The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 20i i
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied: �'-
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Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Prop Address: 1.2 Assessors Map&Parcel Numbers
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1.1 a Is this an accepted street?yes tl no Map Number Parccl Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(it) n
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 Zpne? Municipal ErOn site disposal system ❑
Check if yes
SECTION 2: PROPERTY OWNERSHIP`
2.1 Owner`o ord: AA 0
CA-
Name(Print) t City,State,ZIP
i
6 7- - 00 aW ey a At'i4l.(or,
o.and Street Telephone ail Address
SECTION 3:DESCRIPTION OF PROPOSED WORIe(check all that apply)
New Construction❑ Existing Building LNumbhcnof
wner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Units 2 Other ❑ Specify:
Brief Description of ProposedWorV: ! r r
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
abor and Materials
1.Building $ 1000 I. 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 $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: '52 cc)
S.Mechanical (Fire $
Su ression Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ Iwo ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) /QS.7S1 -�Fr
—A d4 n, Q clr License Number E ration Date
Name of C L Holder f�ee+ List CSL Type(see below)
$! P lP a wA S U
No.and Street Type Description
On�Q _Q D IQ CL'� U Unrestricted(Buildings u to 35,000 cu.ft.
i /( I D l R Restricted I&2 Emily Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
,y_ SF Solid Fuel Burning Appliances O Q�prn 6 LOAIJGJial eyaAOflloM I I Insulation
Telephone Email address/ D I Demolition
5.2 Registered Home Improvement Coonptrra�ctor(HIC) 1 72-272
HIC Registration Number Exp a' it lion IIate
HICI'll)om _
p� ((ln 10 S RRRR�s ant ame
No. d((Sttre� T �SLY(Lrl ULonSiT'�C.�iA'1
W, m Mfl iQ�4 g18=210-6?IS— Email add a
Ci /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 authorizeA44m U1l.AA
to act on my behalf,in all matters relative to work authorized by this building permit application.
l 2 ��
Print Owner's Name(Electr6nic Sigr r at
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 application is true and accurate to the best of my knowledge and understanding.
Mom 6hr)dI4'-a t21-� 41
Print wner'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/dns
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
P
ber of bathrooms Number of half/baths
of heating system Number of decks/porches
of cooling system Enclosed Open
"Total Project Square Footage"maybe substituted for"Total Project Cost"
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