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8 BORDER ST - BPA-12-512 SOLAR !! The Commonwealth of Massachusetts Board of Building Regulations and Standards CI"fY OF 9�I Massachusetts State Buildin g Code, 780 CMR SALEM '�yYre� 6 Revised,var 20/1 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Funtlly Dwelling This Section For Offlg.W Use Only Building Permit Number: Di Applied: Building Otlicial(Print Name) Signature Date SECTION 1:SITE INFORMATION I.`I P erty Address: 1.2 Assessors Map& Pare umbers 1.la 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 tD Frontage(It) 1.5 Building Setbacks(ft) Front Yard Side Yards Bear 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❑ Private❑ Zone: _ Outside Flood Zone? Municipal Cl On site disposal system ❑ Check if yes[] SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: MAh.2.r.n2A !—A' L S AL—.a.r,. N.m,e(Print) City,State,ZIP S ' No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek all that apply) New Construction❑ Existing Buildin Owner-Occupie epairs( Alteration(s) ❑ I Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify: Brief Description of Proposed Work': -rm e)p SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ I. 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 S 2. Other Fees: $ 4. Mcchanical (HVAC) S _ List: 5. Mechanical (Fire $ Suppression) Total All Fees: S 4 ry Check No._Check Amount: Cash Amount: 6. Total Project Cost: $ S c 1 O ❑ Paid in Full ❑Outstanding Balance Due: Lc k i SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) eld %'-eS License Number Expiration Date Name ol'CSL I folder 3 2 List CSL'I'ype(see below) No.and Street Type Description xlJA ,� (qt �© U Unrestricted Buildin�s u' w 35,000 F9� D R Restricted 1&217amil Dsvellin C uyllown.State,ZIPP M Masonr RC Roofin Coverin WS Window and Sit'in- SF Solid Fuel Burning Appliances I Insulation Telephone Email address U Demolition 5.2 Registered home Improvement Contractor(HIC) _) eo � ( � 6 -i3- (t Lpa y Name � is Re`� �"� I11C Registration Number Expiration Date IdIC'Company Name or f IIC Registrant Namc ad Street ta E�ns>yM8 Ol �tt a `1-18S3iR.-)3 Email address Of /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 to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date 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. Print Owner s or Authorized Agent's Name electronic Signature) Date 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. I42A.Other important information on the HIC Program can be found at v sw_n1:uov hca Information on the Construction Supervisor License can be found at torsi .nia,;.go_v,Up= 2. When substantial work is planned,provide the information below: Total Boor area(sq. ft.) (including garage, finished basement/attics,decks or porch) Gross living area(sq. R.1 Habitable room count _ Number of fireplaces Number of bedrooms Number of bathrooms _ Number of half/baths Type of heating system Number ofdecks/porches Type of cooling system _ Enclosed Open t. Total Project Square Footage"may be substituted for''fuutl Project Cost"