130 BOSTON ST - BPA-2014-774 U8 WINDOWS __Fi3 - i Lj_ i (,� .3 -7
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Building Permit Application To Construct,Repair, Renovate Or Demolish a Revised Mar 2011
One or Two Family Dwelling
r This Section For Offieiai Use only,,,,
Building Permiit Number
Date-A'
1 A 4
Bmlding-Official(Print Name) '+ nl
Signature On '
SECTION 1:SITE INFORMATION
LI Property Address-
1.2 As Map&Parcelhgvmbers
l.la Is this an accepted street? s N I
Ye- no—_ Map Numbzr Parcel Num --
1.3.Zoning Information: _
1.4P1roperty Dimensions:
Zoning D— r 'O 8 y� C%Gfe�
Proposed Use LotArea(sq ft)
1.5 Building Setbacks(ft) Frontage(ft)
Front Yard
Side Yards
Required Provided --- -. Rear Yard+, 6fi
Required Provided Required rprovid
1.6 Water Supply: Cl) y=
pp y: (M.G.L c.40,§54) 1.7 F1ood Zone Information: r'a
Public❑ Zone: 1.8 Sewage Disposal System.
Private❑ ._ Outside Flood Zone? - r 3rn
Check if yes❑ Municipal❑ On site disposal systeXi
SECTION.2d•PROPERTY OWNERSRD'1 . m 2 Owners of Record: -
�b co, il . I
Name(print) CI' 0 t j
City,State, IP 'f
No.and Street --- 'S d-G!, I I�'7 -
Telephone Email Addiess
SECTION 3:DE;SC_RIPTgON OF PR9POSED R ORK'(check all that apply)New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs
Demolition (s) Alteration El Addition El❑ Accessory Bldg. ❑ Number of Units
Brief Description of Proposed : Thy I I Other ❑ Specify:
Work
-- --_
SECTION 4:ESTIMATED CONSTRUCTION-COSTS x
Item Estimated Costs:
Labor and MaterialsOfficlal,l;Jse Only
1.Building $ 1 Bmldipg Permit Fee $
Indicate how fee is detemm�ed.,2.Electrical $ ❑Standard City/.6wh Application Fee', _
- --
3.Plumbing - _ —. _ ❑Total Prgect Costa(Item 6)x multtpher x
- - - - -
-- OtherFees
4. Mechanical (HVAC) $ Ltst.
5. Mechanical (Fire
Su ression $ Total All Fees $ ,
6. Total Project Cost: $ a � p Ov Check No Check Amount'
Cash Amount:
❑Paid in Full �Outstanding Balance
Tb
►�n t_%E:D
; SECTI,ON 5: CONSTRUCTION SER,YI_CES
5.1 Construction Su ervisor License(CSL)
—� r�,J
v� J �XO License Num er Expiation Date
Name of CSL Holder f
�b Ced g r, SE, List CSL Type(see below) U.
No.and Street .Type Description ,
Unrestricted(Buildings up to 35,000 cu.ft.)
CiI own,State,21p Restricted 1&2 Famil D ......
M Maso
Y/E��•.— RC Roofm Coveriu
WS Window and Sidin - - -
� //''� SF Solid Fuel Burning Appliances— ka ress c I Insulation
Tele hone Emaill address D Demolition
5.2 Registered Home Improovemeat CnAtractor(HIC) _ -
GIS—
No. O C�a-Fsn ✓ I `J 5 �
HIC Cme or HIC.Regi r t Name - -- I HIC Registration Number Expiration Date
ic � ffl dbilm 1�A Dina/ nn
and Sheet r7lTZT'1a'a�l"t-.Ck/J'6 Cd M
7�1�G33'�)Lo Email ad ss
Ct /Town,State,ZIP J Tele hone
SECTION 6:WORKER$'COMPENSATION INSURANCE AFEHDAVIT(M.G.L.a 152.§-,25C(6)) .'
WorkeWorkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
rs
affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION 7a:OWNER AUTHORIZATION 'O BE COMPLETED OWNER WHEN
'S AGENT OR CONTRACTOR AEPliIES FOR BUILDING PERMIT
I,as Owner of the subject rroperty,hereby authorize �etJrpCD ��Q, �G-i-�7
to act on my behalf,in all matters relative to work,authorized by this buildi g permit appl cation.
Print Owner's Name(Electronic Signature) Date
SECTION 1b: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.
Fruit Owner's or Authorized Agent's (Electronic Signature) ate
„ 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.niass.gov/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)
-- - '-Gioss`Iivin -area=s .-ft. __ ------
g ( 9 ) ,� — -- -- _'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"