21 BROAD ST - BUILDING INSPECTION The Commonwealth of Massachusetts ;INSPECT IONt, 4 V
Board of Building Regulations and Standards " r�1tIeF.
F fqi 1 Massachusetts State Building Code,780 CMR SALEM
�sLLn. 201 b H�Y 2 Rpnsed�vTar 2011
Building Permit Application To Construct,Repair,Renovate Or Demotes a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date plied:
LO
Building Official(Print Name) Signature Date
1
�1 SECTION 1: SITE INFORMATION
y 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
a� c3r��d st 4V, vn✓-} �5- �v6 y V07-
1.la Is this an accepted street?yes ✓ no Map Number Parcel Number
rr 1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
11 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'
2.1 Owner'of Recor d: �t� ,1,1
3 � 2152A5 '/o —JUJU^ �Ix lls 6(e%e�P Mfg
Name(Print) City,State,ZIP
3(0 n ' J C.�r<.& y I- 17- 7°� ass A III vl1on, n
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alterations) ❑ I Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Workz: fdxp . c ab
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:
2.Electrical $ ❑ Standard City/Town Application Fee
❑ Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
/�
Suppression) Total All Fees: $
�� Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ -3� ❑ Paid in Full ❑ Outstanding Balance Due:
VYl K31.0 a�Q -rb G c S �Z�
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
Brad A jv v% Cse / yay a .oY zel
License Numberer Expiration Date
Name of CSL Holder
�N� GJq,�,l � List CSL Type(see below) U
No.and Street Type Description
/j(1 r /_ [ 0 /�n /�. i (i U Unrestricted(Buildingsu to 35,000 cu. ft.
�°�01 LQ.r i141 '1 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
/W SF Solid Fuel Burning Appliances
1 3WL I I Insulation
Telephone Email address D Demolition
5.2 Registered Home I ip`rovement Contractor (HIC) /9 a J R2. s- �1,
�ad Z, HIC Registration Number Expiration Date
HIC Company Name or HIC Re istrant Name
116 6/o4 l sf #7 �Gc��l3�✓lls�/17D�i I Cd.ti
No.and Stree;1&.1 I I MA O ILK I N L Em '1
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 q3r,� rl4t,
to act on my behalf,in all matters relative to work authorized by this building permit application.
` SAY 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 curate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) f Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hives 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.goy/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"