154 BOSTON ST - BUILDING JACKET 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
V\ One-or Two-Family Dwelling
This Section For Official Use Only -
'BuildingPermitNumber: - - Date A
"Building Official(Print Name) Signa ur Date
"•. SECTION 1:SITE INFORMATION
1.1 ProperAddress: 1.2 Assessors Map&Parcel Numbers
1.1a 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 Q"er Private❑ Zone: _ Outside Flood Zone?Check ifyes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
V A \ 9S2,i : (Z-aA N- Nc1 " ADD 2. PA
Name(Print) City,State,ZIP
sy _I Z) t)- %A - M,A, r.. 4?A %- )-k-II - adsoz
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all thaf:apply)
New Construction❑ Existing Building M,- Owner-Occupied ❑ Repairs(s) Alteration(s) Erl Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify;; ..
Bfief Description of Proposed Work 2: " `t- �J
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
^ ❑Standard City/Town Application Fee
2.Electrical $ �-( S ❑Total Pro'ect Cost'(Item 6)x multiplier x
3.Plumbing $ f o2�_Q) 2. Other Fees: $
` 4.Mechanical (HVAC) $ List: .`w
5.Mechanical (Fire ` '$
Su ression $ Total All Fees: $
q � Check No._Check Amount: < <::.. Cash Amount:
6.Total Project Cost: $ ❑Paid in Full 0 Outstanding.ljalance Due:
'+ SECTION 5:.CONSTRUCTION SERVICES " - -
5.1 Construction Supervisor License(CSL)
1 !� CS `a9gs� 12
�'\ tJ V ` s��, �� \'r-� License Number .Expiration Date
Name of CSL Holder
S` -P�,fv`V—O _p C C 4i. List CSL Type(see below) .�t
No.and Street � Type zDescription
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted I&2Tamily Dwelling
City/Tom,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
\.'1 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) '
HIC Com an Name or HIC R � HIC Registration Number Expiration Date
p y gistren[N e
� �
�o.and Street Email address
City/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 .......... ❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION_TO.BECOMPLETED:WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDINGPERMIT
c;d:
I,as Owner of the subject property,hereby authorize �° t�) S�'� A�8\Pr
tl
to act on my behalf,in all matters relative to work authorized by this building permit application.
V A \ Q .r iz-, A M K C 1,,A 4 (Z
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all,ofrthe information
contained in this application is true and accurate to the best of my knowledge and understanding.
r
Print Own r s 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 HTC1 Program can be found at
3nnK.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dns
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" -
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