4 CAULDRON CT - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
V79 Massachusetts State Building Code, 780 CMR SALEM
Building Permit Application To Construct, Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
Ttus Build Section For Official Use
g ermitmb Only
m P Nuer fl
a e Applied i✓` rn
y
Building Of&ctal(Print Name) -
iSignatur
V I SECTION I.-SITE INFORMATION ;
1 1.1 Property Address:
1. Assessors Map&Parcel Numbers A
_ 1.1a Is this an accepted street?yes no Map Number /��--- __n
1. .Zoning Information: Parcel Number rV rV
_N
t 1.4 Property Dimensions:
—L1 —F�—� e >�a t� I 23 ac.r-e,
Zonin' istrict Proposed U e
Lot Area(sq tt) Frontage yt)
1.5 Building Setbacks(ft)
Front Yard Side Yards
Required Provided -- -. Rear Yard
Required Provided Re aired
q Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information:
Public❑ Private El -. Zone: Outside Flood Zone? 1.8 Sewage Disposal System:
# - Check if yes❑ Municipal❑ On site disposal system ❑ -
SECTION 2: PROPERTY OWNERSHIP' -
.] Own ri of Record: -
ft r 4)h to � {�
Name(P -, AC)pr,-� I o )l (�19"- 0
y _CG ��` City,State,ZIP
vn G+,
No.and Street ------ lm_-9T�`�j
Telephone Email Address"
€,ECTION 3 D SCRIPTION OF PROPOSED WORK=(checK'all that apply) ,New Constmction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s}i ' Alteration(s) ❑ Addition ❑"
Demolition ❑ Accessory Bldg. ❑ Number of Units
Brief Description of Proposed Work: �h Other ❑ ,Specify:
Gll
P
SECTION 4:ESTI_ ,ATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Officlal`Use Only
1.Building $: po 4-:'. Building Penmt
't Indicate how fee is determined;;
2.Electrical $ ❑Standard City Town Application Fee =
3.Plumbing_ $_ -- ❑Total Project Cost'-(Item 6)x mulhpher x
-- -- Othei
4.Mechanical (HVAC) $ List: ' r
5.Mechanical (Fire
A.b„
Su ression) $ Total All Fees $
6. Total Project Cost: $ 1 cc, Check No.` Amount: `
Check . �Cash Amount:
6'� ❑Paid in Full ❑Outstanding Balance Due.
mA,I � ��
SECTION 5: CONSTRUCTIQN SERVICES
5.1 Construction Supervisor License(CSL)
by m m FJ>KLl� License Number Expiration Date
Name of CSL Holder
a b CC d ( ` List CSL Type(see below)
INo d_Strleet Type Descripfion .
U Unrestricted(Buildin so to 35,000 cu.ft.)
City/Town,State,ZIP - Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
1 WS Window and Siding - - -
-7 /` n SF Solid Fuel Burning Appliances
-410a Dr46X,5n lr-' orr� an I Insulation
Tele hone Email address D Demolition -
5.2 Registered Home Improvement Conractor(HIC)
e � LLL
^^C''Co ,y ame or C Registrm 'ame -- HIC Re(g��isfration Number Expiration Date
No e�Gr ` Yil7iD 6 �CI.J r6 GO No. d Sheet Email address
1 t���by/n I�fl I) I�bl ],6j '�133 'q1DD
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 1rE-COMPLETED WHEN '
OWNER'S AGENT OR CONTRACTOR APPLIES FOR:BUILD'ING PERMIT
I,as Owner of the subject property,hereby authorize--SW.-
to act on my b-�e��half,,in all
�� ttt�maers relative to work authorized b this building ermit applic ton.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:Q*MW 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.
Prhrt Owner's or Authorized Agent's N e CEI ct, nic 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch)
-- - --- ft.) _
— — Gross 1iJih 'atea s . ----- - - -----
g 9 -- -- -Habitable room-count - ---------- --
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfibaths
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"