109 BOSTON ST - BPA-13-748 DECK REPAIR s�
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building� Code, 780 CMR SALEM Revised Mar 2011
Building Permit Application To Construct, Repair,Renovate Or Demolish a
n One or Two Family Dwelling
This Section For Official Use Only r
Building Permit Number:' Date Applied:
7
But g 0 icial(Print Name). Signatu e ate
SECTION 1:'SITE INFORMATION, , .r`
1.1 Propegrty Address: n 1.2 Assessors Map&Parcel Numbers
�� OSTf�^ S 7-
1,1 a Is this an accepted street?yes i-1 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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑
4
SECTION 2:'_,PROPERTY OWNERSI IV
2V wneri of R/1 O�cor /htfY" SO / (2 f V-elL I- d15 s—
N €(Print) City, ate,ZIP
a 1-eY, S ;W-332-&,11 (-'q
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION PROPOSED WOW"(check all that apply)
New Construction ❑ 1 Existing Building ❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bld . ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work'
d
SECTION.4: ESTIMATED CONSTRUG.TION COSTS'
Estimated Costs: a."' "r 7
Item OfScrahi se Only"
Labor and Materials t - _ >
1. Building $ 1 .Building Permit Fee: $rt Indicate how fee is"determined:
❑ Standard Crty/Town Application Fee
2.Electrical $ s s, a- .
❑-Total Project Cost (Item 6)x multipher x
3. Plumbing $ 2. OtherFe CS:_,$
4. Mechanical (ITVAC) $ List,,
5.Mechanical (Fire
Suppression) $ Total All Fees: $
Check No. Check Amount Kash Amount
6. Total Project Cost: $ ��� El Paid in Full zEI Outstanding Balance Due: '
SECTION 5:`CONSTRUCTION SERVICES7 W
5.1 Construction Supervisor License(CSL) CS- 3L�Q'72�
License Number Expiration Date
Name of CSL Holder � ,
List CSL Type(see below) C-r
No.and Street �c:�"P� ,*_,€ Dpscnptton
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town, State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
P
p SF Solid Fuel Burning Appliances%O - �IE� `�r6j� I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improve,ee,gent Contractor(HIC) /(J ] 96
���'^ ��//!`TC�� u�-��^�' 7• HIC Registration Number Expiration Date
HIC Company ame or HIC Registrant N�
No.and St ��6 G
Email address
Ci /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 .......... I6- No........... ❑
" SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT'OR CONTRACTOR APPLIES IFOR BVILDING.PERMIT
1, 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,"....Bymy name below, I hereby attest under the pains and penalties of perjury that all of the information
this app icy tion is true and accurate to the best of my knowledge and understanding.
Print Owners or Authorized Agent's Name(Electronic Signature) 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.aowoca Information on the Construction Supervisor License can be found at wwcv.mass.eov^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"