2 CABOT ST - BPA-2012-954 The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code 780 CMR,7 s edition OF SALEM
Revised January
Building Permit Application To Construct,Repair,Renovate O emolish a 1,2008
One-or Two Fa elling
Tpisi4 X'° 'ieti3l i '
Building 1�erttiitiNurrtber: a' " ' ' aA ,� ��>i#hed•,•;;, 1
ature.
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1.1 Property Address: 1.2 Assessors�Map&Parcel Numbers
L 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 ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTtart�,'i*Ro ��' l '�rrl✓i�sllt�'`
2.1 OwS�er'otv,,of
Record: _
„L
Name(Print) Address for Service:
rib I� rli
Signature Telephone
SECTIOIH 3 DES(RIP 1171` „ILY4jPOSE�?x1Y2R (cbeck 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': S T ,J
_,7,4 o �e Gf� D C
SECTION4 ESTFZl7ATCONSTRUILTION'COSTS
Estimated Costs '
Item Labor and Materials 0ffiaightJse On1V
1.Building $ IL,fBUiIdhi9Tozmit'Fec]$' - Indicate how fee is determined:
2.Electrical $ `L9iS d rd C o ti tadanylTxvifsAppheaott,Fee -
[3 ToY�ro�ect Cyst'(Item 6�x rhtilttplier x
3.Plumbing $ eFTed
4.Mechanical (HVAC) $ fist
i r
5.Mechanical (Fire
Su ression $ Total till i Ees 6.Total Project Cost: $ $
��� M Na Check Amount: Cash Amount:
p paid tti Fitll ❑Outstanding Balance.Due:
i
sEcrrcaly �rsmxzlr =`Eitar� s.
5.1 Licensed Construction Supervisor(CSL)
MJCJ a e ( License Number Expiration Date
Name of CSL-Holder List CSL Type(see below) y
5 �ti fl I I U-y00 c1 /� Il`P rS. D�sari'tion
Address n - ' -
-'] i( � i U Unrestricted(up to 35,000 Cu.Ft.
,/ �C�r i.✓"t- R Restricted 1&2 Family Dwelling
Signature Z M Masonry Only
�7�' •S 13 RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Register I H e I tprovement Cont ragt rrIC) j 1 (i 8,Ti
LL
HIC Cot�pangName o rC Reg t�attt; me Registration Number
Address /G,,,bVl�1a.�%[.Z�/ (� `7 cf::z Q
Expiration Date
Signature VV�I / Telephone
SECTIOM6 WORL{ERS'COMPENSgTLgN 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...........❑
SEC CdON 7a UlV TER AIFI I ORIZ A ICON r.r 4BE MI'rT�r`� IlMIIIE K
OWNER'S AGENT.OR GON I RACTf1R ABPJ 35 F( I1TIYIVZ,I?)ERMTC
I 6 Ci t S PS /I/? )' as Owner of the subject property hereby
authorize _ h IL<=d to act on my behalf,in all matters
relative to work authorized by this buildin6permif application.
Si tore of Owner Date
,SEA1IUN7 ,bWNE pIF (I T O k '_ ) ;AGL1ya DECLARAT)ON
as Owner or Authorized Agent hereby declare
that the statements and informatio on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
L l
Print Name /,,
/ ///A n/Li[� -,
Signature of Owner or Authorized Agpt Date
Si ned under the sins and penalties of a 'u
, - 77777777777
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 1 tO.RS,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"