24 BOARDMAN ST - B-16-1329 RENOVATE 1ST FL UNIT Z 2_0 cK
The Commonwealth of Massaelte2Ssl�td 'L �3ER+V'ic- a
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Cod-�778q SALEM
P 1' 50 RevisedMar2011
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:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
2N &o'Y VuwA S*t 35--0g6o -0
L la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
41poo s-V
Zoning District Proposed Use Lot Area(sq ft) 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 O Private❑ Zone: AE Outside Flood Zone?Check if yes[] Municipal lg�On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
_SQaCb�,1N)f&a/vt <<e ��VJGthtlpsaSb� MA- ol907
Name(Print) City,State,ZIP
l (nal�ot�es ren Lace f�17-167-ZZ6 ).g lard v"i&1 ��'o�wa�7, r
No.and Street Telephone Email Address J
SECTION 3:DESCRIPTION OF PROPOSED WORK''(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s))�f I Afteration(s))f I Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
. .Brief Description of Proposed Work :
t U �, acR 3 1A11 LVS t f
M$g r L'E eAoo r aol ltic la vqA&6 cell 1Le s
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ I�2 000 1, Building Permit Fee:$ ZZ3 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 (BVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ DOD ❑Paid in Full ❑Outstanding Balance Due:
nna, 1'GV Its
ov'l 4 �
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
-�^ g� CS 1 U63�1 41q-
CI,STI 1�3- (A)I LC I f\t t S License Number Exp tion Date
Name of CSL Holder '
2s- �/ \`1\ 's `` List CSL Type(see below)
No.and Street �i Ty Description
L���. \ (./�• OI CiO[.,`- U Unrestricted Buildin s u to 35,000 cu.ft.
�V l Restricted 1&2 Family Dwelling
City/rown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
`,,,, �yyam�__� SF Solid Fuel Burning Appliances
SC635101gS lYK Inn)I�ICe° �lOttr 't `( I Insulation
Telephone V ail address D Demolition
5.2 Registered Home Improvement Contractor(HIC) (` o-a'.o12 10 Z 576g
,- LA � Ls.M- I A-r ; HIC Registration Number Ex irati Date
HIC Com an Nam r HIC Registrant Name
2 MSS /1VC • �ehr ltl= k66meli(-cavl
No.and Street Email address
L`/rvt�l • I� • o\�tO�F 56� 353 `lI�
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 31A5(I Q W I L LA
to action my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) I 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 i is application is true and accurate to the best of my knowledge and understanding.
'uSTf W U-Ii Y
I
Print Owner'f orAlathorized Agent's Name(Electronic ature) 11 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. ove /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.) (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 halfibaths
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"