6 BROWN ST - BPA-12-234 The ConunonweaIII of Massachusetts
Board of Building Regulations and Standards CI'11'OF
Massachusetts State Building Code. 780 CMR SALEM
L " Revised.ILv?tJ/!
Building Permit Application To Construct, Repair, Renovate Or Demolish a
(due-or Two-Fun ill,Dwellhnij
This Section For OfPeiial Use Onl
fflBuildingmit Number: toApplieicial(Print Nmne) Signal a Dale
SECTION 1:SITE INFORMAT
I ro errttY Address: 1.2 Assessors p& Parcel Numbers
1.la Is this an accepted street?yes s/ no Map Number Purccl Numlxr
1.3 Zoning Information: 1.4 Property Dimensions:
Tuning District I'ropused lJse Lot Area(sit tl) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c.40,§54) 1.7 Flood Zone Information: I.8 Sewage Disposal System:
Public❑ Prival� Zone: _ Outside Flood Lone? Munici al❑ On site dis sal s stem ❑
Check if 'es❑
SECTION2: PROPERTY OWNERSHIP'
2.1�7I ffE/V eO lECt9l7 �f�L/9/'I 11WI V M9
N;mte(Pnnl ,r city.State.ZIP
//3 7 eh/elSdf�
No.and Street Telephone Email Addr -s
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Build in Owner•Occupie Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Nurnberof Units I Other ❑ Specify:
Brief Description of Proposed Work-: _
SECTION y: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1. Building S I. Building Permit Fee: $ Indicate how fee is determined:
'. E'leclrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier _x
1. Plumhing S ?. Other Fees: S
a. .Mechanical 1111':\CI S List:---
Mechanical (Fire — -------
Su„ression) S Total All Fees: S_
Check No. ('heck Amount: Cash Aniount
6. Total Project Cost: S ------ — --
��i Cl Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number F-xpiration Dane
N;unc ol'l'SI. I IoI F --------
Liss CSL 1)pe Isee helusvl
Description
U l Inreslricled(Buildill gs Up to 35,000 cu. 11.)
R Realricted 1&2 Famil l Dwelling
City/town.Stme.ZIP AI asonry
RC Roolin g Co%erin
W'S Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
1'cic bona tT,.,,l address D Demolition
5,2 Registered Home Improvement Contractor(111C)
I IIC Registration Number Expiration Dale
I IIC Company Name or I IIC Registrant Name
No.;utd Street Email address
City/Town.State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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........... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPL
OWN ER'S AGENT OR CONTRACTOR APMIES FOR BU DINGPERMI
1, as Owner of the subject property,hereby authorize
to act join my behalf,in all matters relative to work autho ed by this building permit application.
/�y/>q7ri�
Print Owner's Name(Electronic Signature) Date
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.
Prim Owner's or:Authorizvd,\gents Name(Flectrunic Signature) Dale
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 not have access to the arbitration
program or guaranty fund under I.G.L.c. 142A.Other important information on the HIC Program can be found at
wtttt.m:p..�yt,oe,i Information on the Construction Supervisor License can be found at tv�k tt_,nrts;. ps
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. 1i.) Habitable room count
\'umber of fireplaces__-- Number of bedrooms
Numher of bathrooms Nuntbef of half halos ._
fy pe of heating system ..-- _ --- _- _ Number of decks, porches
I)peofcuulingsyslent -. ....._ !inclosed __ Open
3. "Total Project Square Footage-ma) he substituted for-I'otal Project Cost'