35 BOARDMAN ST - BPA-10-1011 PLASTER/ELEC IN 4 ROOMS �I / I
C The Commonwealth of Massachusetts
Boa rd of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 C'MR, 7m edition OF SALEM
t Reriser/Jusuury
Building Permit Application To Construct, Repair, Renovate Or Demolish a /. aoar
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied: 1
Signature: -'i.2-u � n19//�
Building Commissionerl Ins of Buildings Date
SECTION 1: SITE INFORMATION
/� 1.1 Prope Address, ( 1.2 Assessors Map di Parcel Numbers
v 1.1 a Is this an acce ted street?yes no Map Number Parcel Number
LJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§$4) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
Owner'of Recyid:
n f s:�i Lam/ �� 2bM.¢.✓ S i-i[a�
Prim) 'T� Address for Service:
Signature Tercph'one
SECTION J: DESCRIPTI N OF PROPOSED W RKs(check Of that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) 01 Alleration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief escripti nof,Propo d Work': r"
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building 5 1. Building Permit Fee:f Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $
O Total Project Cost'(Item 6)x multiplier x,
3. Plumbing s 2. Other Fees: S
4. Mechanical (IIVAC) S List: L ,
5. Mechanical (Fire S
Suppression) Total All Fees: S
�O Check No. Check Amount: Cash Amount:
6. Total Project Cost: S r ❑paid in Full ❑Outstanding/Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5,1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSI.- I lulder I.isi CSL'type(see below)
rs De Description
Address U Unrestricted(up to 35,000 Cu.Ft.
PR
Restricted IR2 FamilyDwellin
Signature Mason Only
Residential Rootin Coverinfdcphone Residential Window and SidinResidential Solid Fuel Bumin A liance Installation
Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Dale
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152. 1 2SC(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 .......... O No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT/OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, �TC✓�U �,¢8(SL�ki!5/& f as Owner of the subject property hereby
authorize ✓ 157Ac'L LSL to act on my behalf,in all matters
reI , to work authorized b this building permit a ication. q
2/ d
7behalf.
ner Data
SECTION 7b: ERt OR AUTHORIZED AGENT DECLARATION
,as Owner or Authorized Agent hereby declare
ents and information on the foregoing application are true and accurate,to the best of my knowledge and
Print Name
Signature of(honer or Authorized Agent Date
(Signed under the pains and penalties of 'u
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 ag have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations 110.116 and 110.RS,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
). "Total Project Square Footage"may be substituted for"Total Project Cost"