11-13 BOSTON ST - BPA-13-41 ROOF w ,
l 1/ The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM dMar
Revised Mar 2011
c
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
ffi This Section For O ' Use Only
Building Permit Number: Da/Applied:
'IRFnwo �
Building Official(Print Name) Signature D, at
' SECTION 1:SITE INFORMATION
1.1 Propert Address:>:a?:.,�,.,'+ » 1.2 Assessors Map& Parcel Numbers
I.I a 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❑ Private❑ Zone: Outside Flood Zone?Check i f yes❑ Municipal ❑ On site disposal system El
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Recor
Name(Print) ' -1 Irl City,State,ZIP '
tf 3 a� 64 / - s -
and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction ❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
5 ' D /2e. vL.7p
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building �$ O6 - 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cos[ (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: $ 3 Qc) ❑Paid in Full ❑ Outstanding Balance Due:
3
Y
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construe on Supe iso/r/�'icense(CSL)�2 /lf,� License t / m5 6
Number Expiration ate
Name of CSL flolder
,,�, �O List CSL Type(see below)_
102 0L �0 � "�3 Type Description
No.and Street
��� ,/ U Unrestricted(Buildin s u to 35,000 cu.ft.)
(/t lu R Restricted 1&2 Family Dwelling
City/rows,State,"ZIP M Masonry
RC Roofing Covering
WS Window and Siding
'y / SF Solid Fuel Burning Appliances
( � �! / � S 6 I Insulation
Tele one Email address D Demolition (�
5.2 Registered Home Improvement Contractor(HIC) 1,-6 9 S 39 I I
7C3 4 t�
HIC Registration Number Expna ion Wile'
HIC Com any Name or HIC Reg trant Name
No. d tr an e Email address
C own,State,ZIP Telephone f 9
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 ofthe Issuance of the building permit.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION 7a:OWNEIE AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR
`f APPLIES/FOR BUILDING PERMIT
1,as Owner of me subject prop rty,hereby authorize�Or'L //1 Qul/I .fl-7 5� S
to act on m half in a ers relative to work authorized by this buil ing permit application. 11
tr
Print w is Name(Electronic Signature) ate
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pain d penalties of perjury that all of the information
contained in this ap true and accurate to th st of y knowledge and understanding.
Print O er's o [horized Agent's Name( ectronic S' naturey—� 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.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
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 half/baths
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'