40 BOW ST - BPA 15-603 st The Commonwealth of Massachusetts
Board of Building Regulations and Standards RECEIVED CITY OF
Massachusetts State Building Code,78q1CWCTI0NAL SER\ ICESSALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling 1015 JUN 18 A 111' S 9
This Section For Official Use Only
Building Permit Number: Dat pplilied:
Building Official(Print Name) - Signature - Date
SECTION 1:SITE INFORMATION
1.1 Property AddrW: 1.2 Assessors Map&Parcel Numbers
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1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoaing 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 Pmvided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood one Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERT)(OWNERSHIP'
2.1 O ye ICRCRrrl cob:
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Name(Print) City,State,ZIP
1--/t7 5TJe-&Q� -ZG 36-
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WOIW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration ) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other S
Brief Description of Proposed Work-2:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
abor and Materials
1.Building $ ( oL 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard Cityffown Application Fee
❑Total Project Cost'(Item 4)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees:$
9 Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 13 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Superv�i�s/qr License((CCS/L) /� /Oa 1(0
�
�� �5cAZ Yr (/(/'J (, �� License Number Expiration Date
Name of CSL Holder
List CSLType(see below)/
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 co.ft.
R Restricted 1&2 Family Dwelling
City/fown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
7; ,`,&7 M ^ 02 SF Solid Fuel Burning Appliances
7 Vd- I Insulation
Telephone Email address D Demolition
5.2 R�eygiitsteerr9d,Hom unpprroovement ContractorfH`I'Cn)`� / 5-o5-?7
kl/! LIV r`—W/�-�'��z— HIC Registration Number Expiration Date
HIC Company N. ne or HIC Registran�atae
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No.and Street ee�/ V —7 7-�Y Email address
City/Town,State,ZIP Telephone U OZ
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 o e building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION7a.:OWNER AUTHORIZATION TO BE COWLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BU ,DING PERMIT
I,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.
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Print Owner's Name(Electronic Signature) Date
SECTION 7b: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.
Print Owner'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 HIC Program can be found at
MnLMass.eov,'oca Information on the Construction Supervisor License can be found at wsa�v_mass.go`/d/dps
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"