4 CELESTIAL WAY - B-10-226 t �
The Commonwealth of Massachusetts
A Board of Building Regulations and Standards CITY
1 Massachusetts State Building Code, 780 CMR, 7"edition OF SALEM
Revised January
Y/ Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number Date Applied: o
Signature:
Building Co issroner n ctor of Buildings Date
SECTION 1:SITE INFORMATION
I. r Me, A�dr�s: Q., 1.2 Assessors Map&Parcel Numbers
(�GI e.S i1
1.1 a Is this an accepted stree es no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq In Frontage(8)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public YQ Private❑ Check if yes❑ Municipal JK On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1,gwnert n of Record-
/` ^ / s / /
O. @. dr (�QJ S awl WCL�I
r{h�y' Nam (Frio) Address forSe-frvice: �t
`^ si lure • .fJl/hFl e�/ [�lLl
SECTION 3:DESCRIPTION OF PROPOSED WORIe(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ 1 Altennion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other Specify: 1C: en caber J .�
Brief Description of Proposed World:
C?r� i COt1.n OOr
x
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ �S 0 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ Id 1 R, 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire Suppression) $ Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ &Do ❑Paid in Full ❑ Outstanding Balance Due:
SAND 70 t�cr�t ivc
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) —73 14? 1 7 2O 12
Ge i U u3�-,�e— License Number Expiation ate
Name of CSL-Hol er
List CSL Type(see below)
23 Ci1� cnJe/S
Addre� O 11,V Type Description
F
U Unrestricted u to 35,000 Cu.F[.
R Restricted 1&2 Family Dwelling
Si 7S-1 760 ZD-YO M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
Registered Ho a Improvement Contractor(HIC)
W�
HIC Com any N e or IIIC Registrant Name Registration Number
s Gge.d ..J eT mA o��z3 l9 zo U
Address^ �� 7�--�
t a I -760 Z(JJs 6 cpiranon Date
Signature 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, J(7�I. L T�,el as Owner of the subject property hereby
authorize BXUS SEry i ees to act on my behalf,in all matters
rell.'ve to work aut on by his building permit application. /
ture o Owner Date
Si
b/
,�1 SECTION 7b-OWNER`OR AUTHORIZED AGENT DECLARATION
1, 1 y eXcaS 5 Se-V IC2$- ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalfM0A. a�Ded
Print Name t~
__ �Ia 51►0
Signature of Oviwi4brAuthorized Agent ate
(Signed under1he pains and penalties of perjury)
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 M.G.L.c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations l I0.R6 and 1 I0.R5,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 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"
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