14 BURNSIDE ST - BPA-13-469 tl _ The Commonwealth of Massachusetts FOR
h ,- Board of Building Regulations and Standards MUNICIPALITY
Massachusetts State Building Code 780 CMR 7 edtiititt a` tt. USE
Building Permit Application To Construct,Repair,Renovate Or Depltfiit ,a Revised January
461,� One-orTwo-Familyg I, 2008
This Section Fo fficial a Only
Building Permit Number: Date App
Signature: /
Building Commissioned Inspector of Buildings ate
SECTION 1:SITE ORMATTON
1.1 Property Address: 1.2 Assessors.Map�&Pa,41 NAmersi t�t.i;;.
Ll a Is this an accepted street?yes_ no Map Number Parcel Numbe -
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use ' •Lot Area(sq ft) Frontage(11)
1.5 Building Setbacks(ft) -
Front Yard Side Yards Rear Yard
Required Provided Required Provided
?ff�
1.6 Water Supply: (M.OI.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ 'Lone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check ifyes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1,gwner'of Record:
60514- 2ncr � � 1 fez 6S6 l4 Key�toso
Name(Print) Address for Service:
9-7-�_ -`lo!
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK=(cbeck an that apply)
New Construction❑ Existing Build'mg❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ -
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Bri1e11fD�eJscripfon of Proposed Work:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I.Building $ 1-. Building Permit Fee:$�Indicate how fee is determined:
- ❑Standard Cityfrown Application Fee _
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier - x
3.Plumbing $ 2. Other Fees:
4.Mechanical (HVAC) $ List
5.Mechanical (Fire $ Total All Fees:$
Suppression) Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ �360. 01) ❑Paid in Full ❑Outstanding Balance Due.'
J
SECTION 5: CONSTRUCTION SERVICES -
5.1 Licensed Construction Supervisor(CSL) 311
� y -
7 ! '
License Number Expiration
Date
Name of CSL-Holder List CSL Type(see below)
��Iifto StleCt
Address - Salem 01970 Tyne Des " tion
U Unrestricted(up to 35,000 Di.FL
Signature -� R Restricted 1&2 Family Dweilin
M Masonry Only
RC Residential Roofing Covering -
Telephone �y WS .Residential Window and Siding -
�� 7 y 4._ b y� SF "Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(Hie) (/ y1 -�0 7
I- Compan Registration Number
(tt12 ieffrmpp-A-V6'pN
Address Salem MA 01970 ExpiAtion Date
Signature Telephone -
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.152_§ 25C(6))
Workers Compensation lnsurance 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
-�52 I, Pm°a<y i �Y/ta56 as Owner of the subject property hereby
..authorize it �_ a - to act on my behalf,in all matters
relative to work authorized by this building permit application. - - - -
Z��J,
Sr nature of Own r Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
4�2`R' as'Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to thebest of my knowledge and'
behalf" - -
Print Name - -
2
Signature of Owner or Authorized Agent- Date
(Signed under the pains and penalties of 'u "
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(HNC)Program),will not have access to the arbitration -
program or guaranty fund under M.G.L.c. 142A.Other important information on the Me Program and - -
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110R6 and 110.R5,respectively. _ -
2. When substantial work is planned,provide the information below: -
Total floors area(Sq.Ft.) (including garage,finished basement/attics,decks orporch)
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"