107 BOSTON ST - BPA-2010-652 ROOF a The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
'; !y Massachusetts State Building Code, 780 CMR, Th edition OF SALEM
Revised Jannury
0 Building Permit Application To Construct, Repair, Renovate Or Demolish a /. 1008
One-or Two-Fam', welling
This Sectio , or Offl ial Use Only
Building Permit Number: Date XRPIi
Signature:
3 to
Building Commissioner/Inspect&of Buildings ate
SECTION 1:SI%INFOIRMATION
1.1 Pro erty Address:S� 1.2 Assessors Map& Parcel Numbers
/B OS'll e
L 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 11) Frontage(R)
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:
Zone: _ Outside Flood Zone?
Public❑ Private[I Zone:
if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
E 'N L e V�r1V\ C- I O� r7 O�BNS�
Name(Print) Address for Service:
Signature 'telephone
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other fd Specify: m
Brief Description of Proposed Work'-: 6101 1f7Le CO
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building 5 1 )S, U 1. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (FIVAC) S List: �L
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S 00 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) C?,- 451 3 2q/(Z
if ,-JrGr f License Number Expiration Date
Name ol*CSI.-I IuIJer`r SC QeJ�1� vC List CSL Type(see below)
VJ ry Description
ss E- 6-3oo
t aU Unrestricted u to 35,000 Cu.Ft.R Restricted 1&2 Famil Dwellinatum M Mason Onl RC Residential Rooting Covering
'fdephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contr r(HIC) '—� b�
(5ci nc 1)1�.' v.< s��c c6rp '�B ji u s QlconS� J-gistmtion Number
t11C Cum y Name Pr HIC Registrant N�-yne
1\ ��a5� � etiQo�� VtIIeF
A s .; C/ �- 0/7M—y3-1-I Expira
-3ao tion Date
Si lure Telephone G 0
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 ..........)Q No...........0
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 �A S,Un iV^ to act on my behalf, in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I. ANC HS RoA-�\-ri g ,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 1
P '
Si ure of Owner or Authorized Agent Date
Si under the sins and penalties ofperjury)
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 no have access to the arbitration
program or guaranty fund under M.G.L.c. 1 J2A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and I I0.R5, respectively.
Z. 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"may be substituted for"Total Project Cost"