103 BROADWAY - BPA-15-1057 7MALEM
The Commonwealth of Massachusetts 1 UNA Li� Board of Building Regulations and StandardsMassachusetts State Building Code, 780 CNIRSEP 3pBuildinc, Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date plied:
Buildin_Official(Print Name) .Signature D e
SECTION L SITE INFORMATION
1.1 Pro er Address- L2 Assessors Map & Parcel Numbers
`v
1.1a Is this an accepted street9 y s no klap Number Parcel Number
L3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq k) Frontage(k)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
L6 Water Supply: (iNI.G.L c.40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private ❑ Zone: _ Outside Flood Zone?
Check ifyes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2l Owner'�Rp��R�{ ord:
�r f,l IvI I ` l' Scde11n Mtn U [9 7 6
Nam t) I City,State.ZIP
I q 9,-c n5�� 97 9�- -7�-i55 Z;V �
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition Cl
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Bnef(Description ofProposed Work'-: /r1 f' / . ` .�- �i�. ; �I
SECTION 4: ESTINI.ATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Nlaterials) Official Use Only
I. Building $ L 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 (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
6. Total Project Cost: $
Check No. Check Amount: Cash Amount:
g �� (p
❑Paid in Full ❑ Outstanding Balance Due:
'( P, 8
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 7
_ �/
Gc 1!-1 License Number Expiration Date
Name of CSL Holder
//S lyo/ 51 List CSL Type(see below) U No. and Street Type Description
U Unrestricted(Buildings u to 35.000 cu. ft.)
R Restricted 1&2 Family Dwelling
City/Town, Sate, ZIP
bl Mason
RC RooEng Covering
WS Window and Siding
C� SF Solid Fuel Burning Appliances
74/-0y-3-V I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
±� S ✓� cz Inc - Iogloo9
A
HIC Registration Number Expiration Data
HIC Company Name or FIIC Registrant Name
I/ S I,/O ltT2
No
: and Street Mf}- iC)
Email address
L O l`t' GZB-Syr-oY2Y
Citv/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 .........I No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE CONIPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property, hereby authorize__ /I y ir S )r/2
to act on my behalf, in all matters relative to work authorized by this building pen it application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
Bye ring my name below, I hereby attest under the pains and penalties of perjury that all of the information
cont ' d this application is true and accurate to the best of my knowledge and understanding.
N tr 9 -a � _/�,-
Print Owner's or Authorized gent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her�uwn or an owner who hires-an 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.ntassaeov/dns
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) (including garage, finished basemenUattics,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"