1 BROOKS CT - BPA-14-1455 �l3- Lq - IHSS (ol la35��
The Commonwealth of Massachusetts
(9 Board of Building Regulations and Standards RECEI EO §T
WMassachusetts State Building Code, 780 CMR INSPECT10" SEsed�gy�r'p�°1�y
ar1011
Building Permit Application To Construct,Repair,Renovate Or DemobsIL Demoba_ P & T1
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Wied,
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
131ZcDo 4s c-r oAu5M M�
I.la Is this an accepted street?yes x no Map Number Parcel Number
1.3 Zoning Information: 1.34 Property Dimensions:
600
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Budding 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?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
NEAT— O�VY BWERY AIA 01,91
Name(Print) City,State,ZIP
2 RS 'DO b6 G EALLPVYIV
� CO
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) lid 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work :N A d
C[o5�vin/ Fb2c i)r�uSTn tL ul w p IZENU l iV AAJI) gMfH�2
j?t="QAtrJT A� N �'F17�t7
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1.Building $ q 21 000 — I. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
3 000 — ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 5476700— 2. Other Fees: $
4.Mechanical (HVAC) S List:
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 5'010 00 — ❑Paid in Full ❑Outstanding Balance Due:
MNI. L_iE:.0 ( u
SECTION 5: CONSTRUCTION SERVICES
5.1 Construe tion Supervisor License(CSL)
. .J.ol
030030 I Z Cs
A�PAI
_ License Number Expiration Date
Name of CSL Holder '
tZ9S C /��, NS,T List CSL Type(see below)
No.and Street - "'° Type Description
/) W 0 '(�,� )/ U Unrestricted(Buildings u to 151; cu.ft.
Ot State, /- I n t.�% �7 R Restricted 1&2 Farr Dwellin
Cny/I'own,State,ZIP M Malo
RC I Roofin Coverin
WS Window and Sidin
SF Solid Fuel Burning Appliances
M' &GA_?,u=yyf COMG/)ST Mr-1 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
OW A7 2 O F i'QC�� Rte/ HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street
Email address
Ci /Town,State,ZIP Tel hone
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 ..........k .No...........Cl
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 information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized 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
www.mass. ov:%oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
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"
i
- 08/18/2014 10_37 9787449188 NORTHSHORESURVEY PAGE 02
N/F
CAREY
28,70'
N/F N
UPTON w AREA DAY
3600 t S.F.
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14.00��
N/F
KIMBALL 2 1/2 STORY No
DWELLING
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46,50' ; BROOKS COURT
N/F ODELL
REFERENCE: THIS PLOT PLAN WAS NOT MADE FROM
DEED: REG BK. 13892 PC 577 AN INSTRUMENT SURVEY AND IS FOR
THE PURPOSES OF THE BANK ONLY.
PLAN: REC. BK. 1830 PG, 231 UNDER NO CIRCUMSTANCES ARE OFFSETS
TO: JAY LEW 4r NEAL LEW TO BE USED FOR ESTABLISHMENT OF
FENCES, WALLS, HEDGES, ETC.
I CERTIFY THAT THE BUILDING SHOWN HEREON
15 LOCATED ON THE GROUND AS SHOWN AND IT
CONFORMS TO THE HORIZONTAL DIMENSIONAL REGUL4TIONS MORTGAGE INSPECTION PLAN
OF THE ZONING BYLAWS OF THE CITY OF SAI LOCATED AT
AT THE TIME OF CONSTRUCTION OR ARE PROTECTED UNDER 1 BROOKS COURT
GENERAL LAWS CHAPTER 40A SECTION 7. THoF SALEM
I ALSO CERTIFY THAT THE PREMISES SHOWN ARE NOT ��` PREPARED FOR
LOCATED WITHIN A FLOOD HAZARD ZONE AS �n JAY LEW
OEUNEATED ON THE MAP OF COMMUNITY X250102 GAIL L. WEAL VY
SALEM . MA. EFFECTIVE 7 6 014 SMITH
BY THE FEDORAL EM CYMANAGEMENT AGENCY, NO.35U3 SCALE 1' - 20' AUGUST 15. 2014
�
f NORTH SHORE SURVEY CORP.
fA
qh iL�.�-I� rSTEP14 BROWN STREET
pSALEM. MA. 01970
REG. PROFEMONAL LAND SURVEYOR 978-744-4800 / 4092 X
08/18/2014 11 :54AM (GMT-04:00)