1 BROOKS CT - BPA-10-797 The Commonwealth of Massachusetts
1 Board of Building Regulations and Standards CITY
l !jy ) Massachusetts State Building Code, 780 CMR, T"edition OF SALEM
"tow;✓ Revived Junaury
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 'onx
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: qq Date Applied:
Signature:
Building Commissioned Inspector of Buildings Date
SECTION l:SITE INFORMATION
I.1 Prop m'A dreg: 1.2 Assessors Map& Parcel Numbers
� �� SCC
I.la 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 Il) Frontage(Il)
1.4 Building Setbacks(R)
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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ -
Check if yesO Municipal P-On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1Owner'of Record: m
chi r o` 4 -fi, S
p C—\
Name(Print) Address for Service:
Signature - Telephone
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': V
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how tee is determined:
2. Electrical 5
13 Standard Cityrlbwn Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (fIVAC) S List:
5. Mechanical (Fire S
Su ression Total All Fees:S
G Check No. Check Amount: Cash Amount:
6. Total Project Cost: S ('0 p�S rzs) 0 Paid in Full 0 Outstanding Balance Due: -
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) �O �5� ) 1,,O'Y"�
License Number li.xpimttun f ate
Name of CSL-I folder I.ist CSL Type(see below)
2:0 V�— rype Dewri tion
Addrepss U Unrestricted a to 35,000 Cu.Ft.
Cc'2W Restricted IB2 Family Dwelling
Signature --� M Mason Only
�'�� C Residential Roofing Covering
relephone WS Residential Window and Siding
SF Residential Solid Fuel Btunin A liartce Installation
D Residential Demolition
5.2 Registered HoTe Improvement Contractor(HIC) �-
`
RegistrationNumber
I IIC Company Nam or IIIC rgistrant Name
0
Address ���i. I b Expiratio Date lk�
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 2SC(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.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1 ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
NOTES:
I. 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 1(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 110.116 and 110.115,respectively.
2 When substantial work is planned,provide the information below:
Total floors 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"