26 BRADFORD ST - BUILDING PERMIT JACKET SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(C'SL)
License Number Ifcpnation Dale
Nano o(C'SI. I IulJcr
List CSL 1)fk Isec hdowl
T)Ik Description
U I nrestricted(Buildin s uli to 35,000 cu. It.)
R Restricted 1&2 Family Diecllin.
Cilyi foml'State.ZIP M Masonry
RC Rotdin g C'oeerin
W'S Window and Siding
SF Solid Fuel Burning Appliances
I I Insulation
'1'rle hone Finail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
IIIC Registration Number Fspirttiun Date
IBC Compan) Name or IIIC Registrant Name
No. mid Street Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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........... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative Itto/work authorized by this building permit application.
Pri wner's Na ne IE/') ctninic S�gat ue) 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 Dener'sor:Wthorizcd,%gent's Nonic llilcctronic Sign;uure) 'Dale -
NOTES.
I. :1n Owner who obtains a building permit to do his,her own work,or an owner who hires an unregistered contractor
Inot registered in the Hume Improvement Contractor IHIC) Program),will rro have access to the arbitration
program or guaranty fund under I.G.L. c. 1 a'_A.Other important information on the HIC Program can be found at
,,._.1 Information on the Construction Supervisor License can be found at y- p ips g0\ llis
2. When substantial work is planned, provide the information below;
Total floor area(sq. ft.) (including garage, finished basement'attics,decks or porch)
Gn»S tieing area(sy. ft.l _ _ Habitable room count
N'umberoffireplaces.----_- - Number of bedrooms
Nuniher of bathrootis Number of'h:df baths -
1)pe of heating S)stem - _ Number of decks, porches_ -
flpUofCoolln_L' S)slein -- - Enclosed Enclosed Open
i, "Fatal Project Square Footage-ina) be substituted tier"fol;d Project COST"
The Commonwealth of Massachusetts
} Board of Building Regulations and Standards CITY
Massachusetts State Building r Code, 780 CMR, 7ih edition OF SALEM Revised Jwlnury
I4(/n Building Permit pplication To Construct, Repair, Renovate Or Demolish a 1. 2008
One-or rwo-Family Dwelling
This Section For Official Use Only
Building Permit um11 - Dale Applied:
Signature: Nt� r
Builds CUIMM63ionfqYnsWor of Buildings Date
SECTION 1:SITE INFORMATION
I Property Ad ss: 1.2 Assessors Map& Parcel Numbers
ZCo $f S� lA�wlx A A
I.I a 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 It) Frontage(11)
1.5 Building Setbacks(R)
From Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yesCl Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
Ow ert of R cord:
Z0 )f Si . Sale* NIA Olak)
Nume rint) Address for Service: '
((,0/4 wiz /oSz�
ignature TTelepho
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': Gx p,
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011tcial Use Only
Labor and Materials
1. Building S Qpo I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S � �
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S yr DOO 13 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES t
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of C SL-I lolder List CSL'rype(see below)
f Descri lion
res Address U Untricted u to 35,000 Cu.Ft.
R Restricted IR2 Famil Ihwellin
Signature M Maw On!
RC Residential Routing Coverin
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Ruming Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
IC Company Name or IIIC Registrant Name Registration Number
H
Address Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 as Owner of the subject property hereby
authorize to act on my behalf, in ail matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1 �( ,as Owner or Authorized Agent hereby declare
that the statements and information o the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Nam /f �J Ar, 7OI o
Signal ol'Owner or Aut orizedA Date
Si ed,nderthe pins and Enalties of 'u
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 jol have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total Iloors 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
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
yRevised Mar 2011
Building Permit Application To Construct, Repair, Renovate Demoli a
One-or Two-Family Dwelling
This Section For Official Use 961y
Building Permit Number: I Date Appli
Building Official(Print Name) Signatu Date
SECTION 1: SITE INFORMATION Ir
1.1 Property ddr ss: 1.2 Assessors Map&Parcel Numbers
-zL2�
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 Requred Provided Required Provided
1.6 Water Supply: (M.G.L c. 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Publio Private❑ Zone: C Outside Flood Zone? Municipal Ip On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
21.� Owner'of Record:
1 l Iki V-("Sv $SaedA -AnwmAh Sm bct, MA- 01�ig0
Name(Print) /r+ , City,State,—IP II/!
r710 �`�fUY� �. � '' —(DSO 1�.lan�\tn • �ClvtS�i �dt�`�+� 1e
No. and Street elephone Email Addres
SECTION 3:DESCRIPTION OF PROPOSED WORK= (check all that apply)
New Construction ❑ Existing Building Owner-Occupied or I Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other @ Specify:
Brief Description of Proposed Work2:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 3 — 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ U ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ U 2. Other Fees: $
4.Mechanical (BVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 1 3 Q(�J 0 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 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances -
I I.Insulation
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 .......... ❑ No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE-COMPLETED WHEN,
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING 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.
Print Owner's Name(Electronic Signature) Date -
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By enter' g my name below,I hereby attest under the pains and penalties of perjury that all of the informan
con�n isi�is�ate to the best of my knowledge and understanding. �
P ' ner's or Auth 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
mmy.mass.gov/oca Information on the Construction Supervisor License can be found at mnD .mass. o�v/ M
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" maybe substituted for"Total Project Cost"
CITY OF S.U.E.NI, �L�SS.�CHL'SETTS
OCRDL%IG DEPARTMENT
120 WASHLYGTON STREET, 3'°FLOOR
TEL (978) 745-959S
FAX(978) 740-9846
KimBERUY DRMOLL
MAYOR THoaw ST.Pmxs n
DIRECTOR OF PLBLIC PROPERTY/81L DNG CONNISSIONER
Construction Debris Disposal Afriidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section l 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit Al is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11, S 150A.
The debris will
�bee transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of ermit applicant
date
I.hnvlf.La
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
J Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
'21 1
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address, 1.2 Assessors Map&Parcel bers
ZUe rr�l S 1V
1.1 a 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
; T
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 es
SECTION 2: PROPERTY OWNERSHIP'
2. Owner'of Record:
Name(Print) City,State,ZIP
Zp $rej�oa S� C(fl� ICc�d;ti.kiy , a ll
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WOREe(check all that apply)
New Construction ❑ Existing Building 0- Owner-Occupied K I Repairs(s) VL Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units I Other (& Specify: VUCQ
Brief Descriptio�n/of Proposed Work V12: v w
S (- . n
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 3-4-00 . '� I. Building Permit Fee: $ Indicate how feeds determined:
2.Electrical $ ❑ Standard City/Town Application Fee
❑Total Project.Cose(Item 6)x.multipher x
3.Plumbing $ 0 2. Other Fees: $
4.Mechanical (HVAC) $ 0 List:
5.Mechanical (Fire— $
Suppression) 0 Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project.Cost: ,$ 0 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 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
INS Window and Siding
SF Solid Fuel Burning Appliances
I I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
^f 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 afldavit 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 APPLIES FOR BUILDING 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.
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' formation
contained in this application is true and accurate to the best of my knowledge and understandin
,/- - G s4Zoo
Prim O�ymr's or Authorized`Agent's Name4E16Etronic Signature) Me
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.eov/oca Information on the Construction Supervisor License can be found at www.mass.g_ov/dpss
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"maybe substituted for"Total Project Cost"
00 �f
�t l/
1� The Commoinvealth of Massachusetts
Board of Building Regulations and Standards CITY OF
I
Massachusetts State Building Code, 730 CNIR SALEbI Revised rLlnr 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only.
Building Permit Number. D e ApQltedr
t
Building Official(Print Name) -Signature Date
SECTION I:SITE INFORIVIATIO .
1.1 P��erty ddr`eis l.2 Assessors Map Parcel Numbers
1.l a 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 tt) Frontage(it)
1.5 Building Setbacks(ft)
Front Yard Side Yards Reaz Y
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 yes13
SECTION 2; PROPERTY OWNERSHIPy '
2.11 Pwn
.6 rt of Record: e?6 (ZRICIAr 1 Y
Name(Print) �— City,State,ZIP
No.and Street - Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ I Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief D}}escription of Proposed//``��VorkI=: X Aj ' o e
I.e. 'f'� b/72 F �rf A� O S POJ'-
SECTION4: ESTUNIATED CONSTRUCTION COSTS
[tern Estimated Costs: Official Use Only,
Labor and Materials
1. Building S V 1.,Building Permit Fee:S [ndicafe how fee is determined:
O Standard.City/Town Application Fee
❑
2. Electrical $ ...'[atal Pro jectCosts(Item.6)xmultiplier x
3. Plumbin; S 9- Other Fees: .$
1. Mechanical (IIVAC) S List:
5. Mechanical (Fire $
Sn rression) Total All Fees: .$_
Check No. Check Amount: _ Cash Amount:
ri 1'ntal I'teject Cost ,00 ❑ P:1id in Fill ❑ Outstandm, tl dance IM ,
- 3 -
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Gepiration Dore
Name of CSL I[older List CSL Type(see below)
Type Description
No. and Street
U Unrestricted (Buildings up to 35,000 cu. tt.
Restricted 1&2 FamilyDwellin
City/fown,State, ZIP VI Nlasonr
RC Roofing Covering
tV5 Window and Siding,
SF Solid Fuel Bunning Appliances
I Insulation
1'ele hunt Email address D Demolition
R n
5.2 Registered Home Improvement Contractor(HIC)
11IC Registration Number Expiration Date
I IIC 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 .......... ❑ No ...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING 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: 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 true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized A;entIs Name(Electrunie Signature) �— Date
NOTES:
I. :1n Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Home improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program can be round at
www.mssioov-oca Information on the Construction Supervisor License can be found at%rww.nrass.go,, (IL,
2. When substantial work is planned,provide the information below:
ford floor area(sy. R.) —(including garage, finished bascment/attics, decks or porch)
rcoi; living;ue.1(iy. ft.) Habitable room count —
Ntimberoffireplacci Number of bedrooms
Numberofbathroonts Numberofhalbbaths
fvpc of he.uting iySlent _ ..-- —.-_._-- Number of decks/poi chei _...__. _-----_-----
f,peoFcaoling ;�,fe11t 1?11cloicd (ipen
L I'ol it I ngcrt tiyu:u Front lge in.ry 110 ,iib;tinit I fir"I'oa.il I iii'i tit Cost"
alo
S�iTY�f ,
dwell Lot
35
e
z w8.55 ' o o '
d -_
"
,520�2�C7��C� 11"2� CC1012
AWLtcariF K " se e0wioaau locob;o ti of.property: sa/cm.,
13rac�,fard 5mcr �
2 f0t
awe�►cfag 34 Lot 35
gcwage
it 26
t Porgy : �
68.55' cgc r
L
'1 4- �N OF y
4r22*od#1mu 250 fog oco 10 • flood ;gone: C•
PAULGn
,` h�eYf fycertiy '�' at}U$111 tgage imp"non MParA*1r, o - GROVER V
' �"J. Ibhv(l-P Morrb &16ale%m f/U6 - No 31311
9hCd11XUf gdWWM her¢OMd6e5YWt efaUimaspecial. TEMA{�OOd�
ham amcc wide arc effective date of a 5 85 and nhe luuc�ton o�
the dwells g does conFm-tu c ro the local sorting by-laws in.
at-the time oFcot sauction with, respectta horizontal di iona� Scale: V __ sj�v �
setback r+�uu�eilients or is ex�rirprigvir . vlola.tton erf�orczmertt'' .Date: rD >3 og
actwn, tinder Mass. GenerCd IaW5 ChcWtW40A1 SeCi+'10M 7. File No. 09-dA3'7
PLEASE NOTE: The structures as shown on this plot plan are approximate only. An actual survey is necessary for a" precise
determination of the building location and encroachments, if any exist, either way across property lines. This plan must not be
used for recording purposes or for use in preparing deed descriptions and must not be used for variance or building plan
purposes. This plan must not be used to locate property lines. Verification of building locations.'property line dimensions, fences
or lot configuration can only be accomplished by an accurate instrument survey which may.reflect different information than what -
r" is shown hereon. .Please note that this is "NOT A BOUNDARY SURVEY" and is "FOR MORTGAGE-PURPOSES ONLY". -
COLONIAL LAND SURVEYING COMPANY," INC.1 j
269 Hanover Street - Hanover, Mass. 02339 Phone: 781-826-7186 '- Fait:781-8264823` F
i
f
The Commonwealth of Massachusetts
Board ul'Suilding Regulations and Standards CITY
y ) Massachusetts State Building Code. 780 C'MR. 7u`edition OF SALEM
y/ Rvvised Juimmrt•
Building Permit Application To Construct. Repair. Renovate Demolish a /. :/RAY
One-or rrvo- ily Dwelling
This Sec on F4r Official Use
Building Permit Num I UaIeAppijoi- �o4i LO
Signature: �A///ice
Building Commissioner/ ct speur of Buildin Dale
SECTION 1 ITE INFORMATION
1•1 Pope fF1s t � AA
n A 1.2 Assessors Map& Parcel Numbers
I.I a Is this an accepted street?yes no /t W Map Number Pmcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(It)
1.5 Building Setbacks III)
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 19 Private❑ Zone: _ PiCheck if Flood
esw�' Municipal On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
p
rtof Recgrit: �/Address for Service::SECTION 3: DESCRIPTION OP PROPOSED WORK'(check aB fbat apply)
uction❑ 1 Existing Building$ Owner-Occupied Uk Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other )Il.Specify:
Brief Description of Proposed Work': Qyr W ly&C�,,Q¢ ; Fyo e!(
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Offlclal Use Onl
Labor and Materials y
I. Building S S poC6 1. Building Permit Fee: f Indicate how fee is determined:
❑Standard City/Town Application Fee
_. Electrical S ❑Total Project Cost(Ilem 6)x multiplier x �'
5. Plumbing S o 2. Other Fen: S�
4. Mechanical (HVAC) S List:
5. Mechanical (Fire
tilt ression S O Total All Fees:S
Ocap,oU Check No. Check Amount: Cash Amount:
6. Total Project Cost: S �� 0 Paid in Full 0 Outstanding Balance Due:
SECTION 3: CONSTRUCTION SERVICES
p:Njm
icensed Construction Supervisor I,
License NumM lixpimtiun 1}ate
of CSL- I lulder I.ist CSL Type(sce below)
t Descri ion
s U unrestricted to)3,000 Cu.Ft.
R Restricted Id2 Fsmil Uwellin
Signature M M O nI
RC Residential Roolin Covering
feleplume WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Inslallaliun
2DfResidential Demolition
3.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or IIIC Registrant Name Registration Number
Address Expiration Due
Signature 'telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a ISL f 25CM)
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 ..........D No...........O
SECTION 7n:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING 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.
rne
of Owner Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
�� as Owner or Authorized Agent hereby declare
tatement and informati n on the foregoing application arc we and accurate,to the best of my knowledge and
e
.Sigriaturc of Owner or Authorised Agent Uate
7An
the sins and nalties of 'u
NOTES:
er who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
tered in the Home Improvement Contractor(HIC)Program).will_W have access to the arbitration
or gtwanty fund under M.G.L.c. IJ2A.Other important information on the HIC Program and
tion Supervisor Licensing(CSL)can be found in 7R0 CMR Regulations I IO.R6 and I IO.R7,mpectively.
bstantial work is planned,provide the information below:
rea(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
). "Total Project Square Footage"maybe substituted for-Total Project Cost"
Crry FSALE1C
PUBLIC PROPERTY
DEPARTMENT
32
�uauav a�liCall y
Nava. 130 W MUNUMM STMEU 0 -
Y41 r$-745.9S"•FNC WW740.""
APPLICATION FOR THE REPAIR RENOVATION CONSTRUCTION
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY FOR ANY VaSTINGI
STRUCTURE OR BUILDING.
1.0 SITE INFORMATION
Location Named A[ Buiidtng
- Property -. . -.
f3 6or�J
Property Is located In a;Conservation Arse Y/N Historic Dbtrid YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land `
Name: eA L I-TZ '
Address:
3r'r�OFr�O .S( •
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN E7I18IING BUILDINGS ONLY
Addition Existing a
Renovation Number of Stories Renovated
Change in Use Now
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed ork:
m4m)Hr/�,PcUFS �r y� E Trzane� eu�LS, �Ns�4// �w.ti
--- ----Mail Permit to: eq ! -- - -
What is the current use of the Building? Sr�thi L /
Material of Building? r r��.) If dwelling,how many units?
Will the Building Conform to Law? Asbestos?
Architects Name /✓i�}
Address and Phone
Mechanles Name
Address and Phone
Construction Supervisors License* HIC Registration#
Estimated Cost f of 3� Permit Fee Calculation
Permit Fee i '---- Estimated Cost X$71$1000 Residential
_- Estimated Cost X$11/51000 Comme►cial-- -----..An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit tc uild to the abo re stated
specifications. Signed under penalty of perjury
D to 9"ya
C N
O
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