111 BROADWAY - BPA-13-473 Ville Colnnsonweahh or Massachusclis
} l/) 1: Iluard Ofi)uilding Regulations and Standards Cl 0'OF
vvv +r ;, ��lassachtuctts State Building Cute.-780('SIR SALEM 'I
R.,I hell.Ifin.:1//
-Nl Building Permit Application To Construct, Repair. Rclwvate Or Demolish a
Otte-or Avo-feuaik Dtvvl(in•\r
This Section For Otiicial U• Onl
Building Permit Number: Date Ap led:
BmlJing Uliicial(Print Nwnc) Signuturc
j Date
SECTION 1: SITE INFORS TION
1.1 Property AJdrels:' I 1.1 Assess rs,% street Number
I.la Is this an acce led street?yes no Nap Number Parcel Number
I.J Zoning Information: 1.4 Property Dimensions:
7-sing District 1'n7pZwJ llse Lot Area(sy tit , Frontage(It)
1.5 Building Setbacks(R)
Front Yard Side Yams Rear Yard
Required Providvxl Requ(rcd Provided Reyuircd 1'roviJeJ
1.6 IVater Supply;(M.G.I.c. q0•§S4) 1.7 Ftood Zone Inhrmallon: Lg Sewage Disposal System:
Public O Private O Zone: _ outside Flood-Luna?
Check if es0 Msmicipd O On site disposal s)stain O
SECTION2: PROPERTYOWNERSHIPs
2.1 Owner'ofR cord Q
N;unetPrim► Uq,Slala,l.IP
WT.unJ Street ` /' fe rp- tt»ml AJdrcss
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all st-apply)
New Construction O Existing Building O Owner-Occupied 0 Repairs(s) Alterallonts) O Addition O
Demolition 0 Accessory Bldg.❑ Number of Units Other Cl Speedy:
Brief Description of Proposed Work :
SECTION 4: ESTIMATED CONSTRUCTION,COSTS
liens Estimated Costs:
(Latiur msd.\trnrrials) Official Use Only
I. building S I, Building Permit Fcet S ndlcate hosv fee is determined:
2. Electrical S O Standard Clty,Tussn Application Fee
l I'lunihing S ❑Total Project COst'(Ilem 6)x muiliplier
_v. Other l'"s; S
J, \Iedt.mic.d ill1 \('1 S List:
Cu�vessionl S Iblul \11 Fees: S -- .__ .._ .. ._.. ._ . .
n Total Project Cost: 3 Check No. _ _( heck Ansount:
O' ❑ Pail in Full 0 Oulsrmding Bal:utce Due:
SECTIONS:S: ('UNSI'RIK"riON SERVI('F.4;
4.1 Construe lot Supen'Is license(C'Sl.l �9� .._ � —
}}}yyy --- -
�t-� Il�enx Nunlhcr
- - ( — -
V,unc�ll/l�S1 11 I+kr _ I Iit('SL I)pe Ill l+elual.__._ I
Leiyl --- 'f)qt Iktcriplinn
No. ,Ind Street It Ihlrcilricled IIluiidill s tip toi3MIln.11. Ml
R Rntricl¢J LR•2 F.unil -D+,ellin
%I Slason
RC R,talln t'„vcrin
q'S N'indu+r,uldSidi]
- SF Solid I'u¢l Iluming i\pplianeee
p0 Li�yfc„2� Insulation
D
[� hm:ul-uJJreaa,- l) -; umuli(iim
role bans
5,2 Registered llonle In rovem rat C tetor IIIIC) t2�
0
111C Regtstratien Nunlbur I? ,inl un I)+la
I I n q 1 a u a ant
Email address
u. t 5 'et
CI /Town.State ZIP cle hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,e. 132.1 2SC(6))
Workers Compensation Insurance affidavit must be conlipleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuancel building permit.
Signed Affldavit Attached? Yes .......... No•'""""
SECTION Tat OWNER AUTHORIZATION TOO C0111PLETED 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, ;..-
Ite
Print U%l,i a Nutne(Electronic Signal
SECTION 7bt OWNER' OR AUTHORIZED AGENT DECLARATION
By entering illy name below, 1 hereby attest under the pains and penalties of perjury that all of the information
containe It this application is true and occur et the best qAmy knowledge and understanding.
print Unner'.i nr:\urhurinJ,\gelit'v Nunes"l lilac.rnl is.Signaw a ..,. .
No'rlest
is a buildin permit to do his,her own work,or an owner who hires an wv e orb
1rntionuractur
Owner\\ho obtains g P , ve access to the ar
I. .\n bnuaetor 1 HICI Program will ha
n rovemem C •, t m
1 not registered in the lull u h p
program or guumnty I'unJ under\I:G.L.,a. I4'A. Usher important inlurmatian on the HIC Program can be h w,
.4.I In forlin ion on the Construction Supervisor License can be foundat„+\`%
substantial aurk is pl:umaJ, provide the infoltil 11uJingionlyaraye, finished basemcntatties,decks or por0i)
filial dour are.,(sq. 11.) : ---- Habiable room cuuN
Grussli\ingurealsy. 11.l _---.
' Nunlher of heJnlums . .
♦lunberol'tireplaces .. _ —_ Number of halt huths
�unlheraFbadirrollls _ . . . Number„1'Jecks, parches I
i f)pa al healing s)item I�ncll,aeJ .Open
1\Ilk: ,t Caalnlg i\itelll
1. "I n.11 Pfa�e�t Sytlnre 1'aal.11e 11111\ lie itibilitkill tLr••1'al,li I'mject Clot"