4 BROOKS ST - BUILDING PERMIT APP The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
b Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date App fred:
Building Official(Print Name) Signature Date
SECTION I:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
�_lroo_K-s �t se%m z
I.1 a Is this an accepted street?yes. no Map Number Parcel Number o t7f
s m
1.3 Zoning Information: 1.4 Property Dimensions: n
_ 1—I
Zoning District Proposed Use I-o Area(sq ft) Frontage('11) =A
1.5 Building Setbacks(ft) � r<
Front Yard Side Yards Rear Yard D CA
50
Required Provided Required Provided Required -fa ided<
o m
1.6 Water Supply: (M.G.L e.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Zone: _ Outside Flood Zone? —/
Er Private❑ Check if yes❑ Municipal Ifs On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 wner'of Record:
U/`� /1?//U/9(:1 Sig/gym /�lg, (2/R10
Name(Print) City,State,ZIP
� A>--c6_A S, S/- q7u 17-"+s9 itn+Ve20 (2 rt?oi Am 7
No. and Street 'telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other I3-Specify: 4g0Q4S
Brief Description of Proposed Work: &0, ept
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ SS 7 .,5—Z 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ b
❑Total Project Cost'(item 6)x multiplier x
3. Plumbing $ L Other Fees: $—
4. Mechanical (FIVAC) $ ' List:
5. Mechanical (Fire $
�® Su ression Total All Fees: $
eT� Check No. Check Amount: Cash Amount:__
6. Total Project Cost: $ 9 7� S ❑ Paid in Full ❑Outstanding Balance Due:
S'Elv'r T,) t l. O (0 �Z
r r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL'['ype(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(H[C)
HIC Registration Number Expiration Date
Hf(Company Name or I IIC Registrant Name
No:,and Street Email address
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
I,as Owner of the subject property,hereby authorize
to act on my be trlf,in all matters relative to work authorized by this building permit application. �J
Prin Owner's Name(Electronic Si ve) Da e /�
SECTION 7b: OWNEW 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:
l. 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.niass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dns
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"