67 BOSTON ST - BPA-12-863 DECK --- Fhe C'onunonweal(h of Massachusclts
Board of Iuilding Regulations and Standards CITY OF
Massachusetts State Building Code, 730 C NIR SALEM
Building Permit Application 'fo Construct. Repair. Renovate Or Demolish a
One-or Two-Piunilr Drrellin,N
This Section For 011icial Use Only
Building Permit Number. to Appli•
Building 0111cial(Print Muriel SilFnalur Ow
SECTION I:SITE INHIRMATION
1.1 Property Address: 1.2 Assessors Slap S Parcel Numbers
A A r it,., 5�y-
'-__ I.1a Is this an accepted street?yes - 7 no Map Numb:r Parcel Nwnlxr
1.3 Zoning Information: 1.4 Property Dimenslons:
Zoning District lImpused tl!w Lot Area(sq It) Frontage III)
1.3 Building Setbacks(It)
Frunt Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(( . I.c.JU,§Ja) 1.7 Flood Zone Information: tM,
ewage Disposal System:
Ihiblic❑ Private❑ one: _ Outside Flood Zone? cipal❑ On site disposal system ❑
Check if yes❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owpert of Record:
Nance(Print) I City.State.ZIP
No.;aid Street relephune Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteratlon(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ .Spccily:
Brief Description of Proposed Work=: OO it: ' xTA 0C'Cic TL (�C45-frit i r-
1-(r.:• i~f iTti � = aCIF ��tN to .�. �4" 11 r r -l-c
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Itent Estimated Costs: Ofllclal Use Only
I t.abur and .\laterialf 1 Y
I. Building S it' 6 I. Building Permit Fee: f Indicate how lee is determined:
2. 1`.lertrical S ❑Standard CiryiTown Application Fee
❑Tu(aI Project Cost(Item 6)x multiplier _ __ x
J. I'lumM°y S ?. Other Fees: S I / - -- -
4. mc0lanical ill% W) S List:-- ----- YI -----�Y -. [�
' 3. Mechanical iFirc "'--_ttt--- F
tiu�getsiUnl S rotal .\Il Fees:
- --- -- .._ _.__. .__ . .
('hccA No. ('lieck Amount: C.ish \mount:
o Tulal Project Cull: 5 ❑ Paid in Full 0 Outstanding 11.11 mve Due:
SEC HON .S: CONSTRICTION SERVI( FS
5.1 ('onstructioliSul)enisor License((St.)
I iccnse 1",mhcr Npiral1011 Date
Nallic oIT.Sl. I I"Ider I is L.."I. I)rw Isee
I PC Description
and Street 111rustricil A(Iltilldin es u-n M 3
d'
It Re,tricled 1&2 1 mill
- " 't''
KC Rix,fin uo%crin d..
Nk S Window Md S10111
Dwcllin
IIJ , 11
SF Sulij Fuel Ilumills Appliances
I Insulation
I 0cphole Fmall address
D Domlition
5.2 Registered Home Improvement Contractor(111C) I IIC l4ciistration Number -F%piralion Date
IIIC 0millait) Mime or IIIC Registrant Name
No. Aid Street Email address
City/Town, State,ZIP relephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.1 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial or the Issuance of the building permit.
Signed A Mdavit Attached? Yes ..........a No...........0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDINGMIT
1. as Owner of the subject property,hereby outhoriz
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print O%vocr'3 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 t best or my knowledge and understanding.
�,11 l,'141- C� 4-J-7 11-7 C- 5P :?e V I —
Print 0wncr*i or Atilhori/W Ai011 4NUIllu(FICL-donic Signature) DaW
Nurm
1. \n Owner who ubtains a building permit to do his her u%vn work,or an owner who hires an unregistered contractor
gl o'(nut registered in the Hume Improvement Contractor(HIC) Program),will tU) have access to the arbitration
�'r"' 'u .
program or guaranty lund under\f.G,L. c. 142.A. Other impurtant information on the HIC Program can be round at
i Information an the Construction Supervisor License can be found at
2. W hen substantial%wrk is planned, provide the infurniation below:
rota) flooraren I�44. ft.) (including _garage, flnished basement attics,decks or porch)
Gross li%ing area 154 11,1 Habitable room count
\uinher ot'llirclilaccs Number ol'bedrooms
Ile Number ot'decks, pordics
ltpen
i%slclli I'llclo'cd
loial Project Square ,,;I I,c qlb,titu0 Ilor I'ot.fl Project Cost"