40 BOARDMAN ST - BUILDING JACKET i
v
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7°edition OF SALEM
Revised January
Building Permit Application To Construct,Repair, Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
This Section For Official Use Only
�• Building Permit Numb . Date Applied:
Signature: lz? a
Building Commissioner/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address, 1.2 Assessors Map&Parcel Numbers
Q R o it"A60 ST
Lla Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
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 Q1' Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow�ner'ofRecord: L16I�OG /t'tAu� Sir
Name(Prig Address for Service: et'
sir / V Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other QsST=ify: zJSr)�na. o
Brief Description of Proposed Work': littlLitAlCn—t` .✓
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ , O 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ f Z OOO 0 Paid in Full ❑Outstanding Balance Due:
, 1
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) I03 ,y.�Y i -"3 13
Jeffew License Number Expiration Date
Name of CSL- Ider List CSL Type(see below) U
ApitfaBiJi l�
Ad ss pt T Description
U Unrestricted u to 35,000 Cu.Ft.
R Restricted 1&2 FamilyDwelling
Sig M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Regist4Home Improvement Contractor(RIC)
♦ t0"/
HIC Company N �HI Re istrantName n Registration Number
Addres R `40 - al - 20/1
Expiration Date
Signs 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 .......... 0d00' No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR,CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Gf'O uA n6i�06 , as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative t rk authori ed b i building permit application.
Si ure o Owner Date
SECTION 7b:O`WNER'OR AUTHORIZED AGENT DECLARATION
1, J ErFa-e y/ M l�`'7- 07477° ,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.
Print Nam
8- /Ir-sp
Signature Of er Au on Agent Date
(Si ed an. th ins and penalties of
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(MC)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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,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"maybe substituted for"Total Project Cost"