30 BOARDMAN ST - BPA-11-472 INTERIOR RENOVATIONS 1-
a The Commonwealth of'Massachusetts
Board of Building Regulations and Standards CITY
�•
Massachusetts State Building Code, 730 CMR, 7'h edition OF SALEM Krt•i.red Jautuwt•
1 Building Permit Application'fo Construct, R pair, Renovate Or Demolish a /• 'oo,v
One-or Two-Fumil Dwellin
ThisA4ction F Official Use Only
Building Permit Num r Date Applied: I 17 Z O
Signature: Akjl� 11/ F/1'0 -
Buildin bmmis'ioner/In of Buildings Date
SECTION 1:SITE INFORMATION
I.1 Pro erty Address: 1.2 Assessors Map& Parcel Numbers
l.la Is this an accepted street?yeses no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(fl)
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:
/ Zone: _ Out Flood Zune?
Public 0 Private❑ Check ifyes0' Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Recur C I
Nam mt) Address for Service:
97F -7A-Sg817
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ 1 Alteration(s) Erl Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work-: +42, - t'ri A v r'rl r- o7yi
t'�r• tin I� �1.� roa,.v` � i
1ti ry 3 i r �N t (wl
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I. Building S 2 (o,56 r'�". 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S
011)(960, ❑Total Project Cost(Item 6)s multiplier .x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IiVAC) S List:
5. Mechanical (Fire S
Total All Fees: S
Suppression)
i Check No. Check Amount: Cash Amount:
6. Total Project Cost: S r�g J`b - ❑ Paid in Full ❑Outstanding Balance Due:
Zq
2
1
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) /p f SO 3 <O 23(2«
Car t / ki ben 5 Pik License Numtcr Expiration Date
Na ne of GSL- I IulJer 1
L Y List C'tiL I)pe(set:below)l'VI 7ST l US
Uescri tionlricteJ a to 35,000 Cu. Pt.cted I&:2 Famil [)-AlinS Ip6�naW9(ep Onl�D 39 Z � b cntiul Ruulin Cuverinl'ekphone ntial Window and Sidintial Soli)Fud l3umin A liancc Installation
ntial Demolition
5.2 Registered Homy, Improvement Coritractor(HIC)
't"Fti rgvtn<,P�ln Lent y+r^tJ G-I'-t �✓\ �'Zj
I 1IC Company Name or 1 1C Re�istmnt N3 7 Re
g
'istrat
i
on Number
�6 0or �1 . - kl �she�� Ivy L6 4lZ� <Z—
n ess
387657KA� TG. pimtiun Date
Signature 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 APPL S FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize ^�-1R.r'/ O!'Yt S�Y1 to act on my behalf, in all matters
relative to work authorized by this building permit application.
<a Y� I l L2 4 f l b
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, 07Y7.5 e k-L- ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
2r T 177'V15eA,1-
Print N
,I0,_o /
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of cr'u
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. 1 42A.Other important information on the It IC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115, respectively.
2. When substantial work is planned,provide the information below:
Total floors 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 fix"Total Project Cost"