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15 BOW ST - BUILDING PERMIT APPS 2- l 'z10 7 3 ,7 The Commonwealth of Massachusetts • -�� Board of Building Regulations and Standards CITY OF dPt Massachusetts State Building Code, 780 CMR SALEM Revised Mar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Family Dwelling This Section For Official Use Only Building Permit Number: - Date.Ap 'e • Building Official(Print Narne). -`: Sign ure .. Date SECTION I:SITE INFORNIATION' LI Propert Address: 1.2 Assessors Map&Parcel Numbers 6l� l.la Is this an accepted street?yes_p no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq tt) Frontage(Q) 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 El Zone: if yes❑ Municipal ❑ On site disposal system ❑ SECTION 2: PROPERTI(OWNERSHIP! • 2.1 O�n eClTr z-i•f' �LrC/�('tt/t� Sa.IK/� A4A 0 "! 2 o Rime(Print) City,State,ZIP l r- t�y-Pv cr 4?78 3Sr No. mid Street relephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek all that apply) New Construction❑ Existing Buildin Owner-Occupied Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition P Accessory Bldg.❑ Number of Units_- I Other ❑ Specify: Brief Description no�f Proposed Work': i r•n9�e� �C n A,,L ;l SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Nlaterials I. Building $ ©� I. Building Permit Fee:$ Indicate.how fee is determined: �G G ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ SOQ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees:S Check No. Check Amount: Cash Amount: 6. Total Project Cost: S Oki,000 ❑Paid in Full ❑Outstanding Balance Due: • SECTION S: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) ru License Number Expiration Date • Nine of CSL HoldereJJJJr I List CSL"type(see below) No,mid Street T Description ' S0. A A �' 7© U Unrestricted(Buildings tipto 35,000 cu. lt.) /1fI Restricted 1&2 Family Dwelling City/foevn,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) ,42?LY /,.K yl(J V"�!l C,BC� HIC Registration'Number Expiration Date HIC Company Name or HIC Registry Name G,7 fMohutrrt�vtf � r7c Scryl [ @ �jWla�� - No.anrddQVrt'(Uj �. � ' � Email address A / 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 BE COMPLETED WHEN. OWNER'S AGENT OR CONTRACTOR APP((LIES`FOR BUILDING PERMIT'. I,as Owner of the subject property,hereby authorize Ltct// [tOtg.Q arms l • t9 action my behalf, in all matt s r alive to w autho ' this building permit application. Print Owner's Name(Elec roni re) 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 of the information contained in this application is I and ace fr te to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) Date 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 not have access to the arbitration program or guaranty fund under I.G.L.c. 142A. Other important information on the HIC Program can be found at www.mass.gov oca Information on the Construction Supervisor License can be found at www.ntassarzov:/dns 2. When substantial work is planned,provide the information below: Total tloor 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" • The Commonwealth of Massachusetts OF Board of Building Regulations and Standards CITY S M Massachusetts State Building Code,780 CMR d Mar +) Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Dem ' a One-or Two-Family Dwelling \ This Section For Official Use Only 1 Building Permit Number: Date Applied: ef- Building Official(Print Name) Signature Date SECTION 1:SITE INFORMAT16N 1.1 Pro a Add 1.2 Assessors Map&Parcel Nginbprs �v �� 1 SUt.J I �j `oV Lla Is this an accepted street?yes_ no Map Number Parcel Number 1. _pipR Information: 1.4 Property imenshms: Zoning District Proposed Use Lot Mea(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❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2-Me �Recor�e U Sa)Cry I v g1 c, n 19 7 d Name(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3:DESCRH'TION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Buildin Owner-Occupied Lpef Repairs(s)Jg4 Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify: Brief Description of po� d Work?: Y C)e iz n r i rl O in SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials 1 Building $ 00 CA 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (Ii:VAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ I �� Q� 13 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street Type Description U Unrestricted(Buildings up to 35.000 cu.ft. R Restricted l&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Lmulaho- Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.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 ..........O No...........O SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I the subject property,hereby authorize IO/X�/X rx-j) to act on my b ha l -r all ma 've to rk authorized by this building permit application. 's Name lec ra ue Date SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION B enteri my below,I hereby attest under the pains and penalties of perjury that all of the information ontai i is on Is ac to the best of my knowledge and understanding. Z ri zed Agent's Name(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 mnm.mass.eov/oca Information on the Construction Supervisor License can be found at m2n .mass.eov/dos 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basementlattics,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"