10 CHANDLER RD - BUILDING PERMIT APP (003) $ 12 (o cr-io3z
The Commonwealth ofMassachu ECTIONAL SERVIC CITY OF
Board of Building Regulations and Standards ;
Massachusetts State Building Code,7'
SALEM
9 A24
Revised Mar 2071
(� Building Permit Application To Construct,Repair,Renovate r De a
V` One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
S � I�• ISo
1 Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address 1.2 Assessors Map&Parcel Numbers
/0 CAA f7� Sam.=14
1.1 a 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 f) Frontage(ft)
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:
Public 53' Private❑ Zone: _ Outside Flood Zone? Municipal ffl On site disposal system ❑
Check if yes[]
SECTION 2: PROPERTY OWNERSHIP'
2 Owner'of Record:
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Name(Print) City,State,ZIP
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No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) to Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: I riu' h,
Brief Description of Proposed Work , 'NCO M ' '%q hl'A'✓E 1-Al' Rre:vr '/Z- 94* ,fiis
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SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ Q-yp 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ T
4.Mechanical (HVAC) $ List: D
5.Mechanical (Fire $ Total All Fees:$
Suppression)
i Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ /0 f6 ❑Paid in Full ❑Outstanding Balance Due:
-2S1- ySll- 5(A o9
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) �� � ,.��2� I I u
LiceJnse',Nu7mber Expiration Date
Name of CSL Holder 1
� List CSL Type(see below) V
/o2���&�
No.and Street —N Type Description
^n U Unrestricted(Buildings up to 35,000 cu.ft.
�&l/a a^OS CO /Y/ /�U 7 R Restricted 1&2 FamilyDwelling
City/town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
ff SF Solid Fuel Burning Appliances
1/4sy-�ZSf)"�✓Mr-fC-�QASc'al�v;�° ti✓ftiuo C.-J.✓I I Insulation
Telephone Email addres D Demolition
5.2 Registered Home Improvement Contractor(HIC)
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1 11L=or9 '� 44 HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
/may AILIAW&C-10ylgdCrDiZA (50tyt P<r 4�tCo C'A
No Prrd Street
L/(I/-S-br;4 Email addre
Ci /Town,State, IP
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 ..........15-- No...........0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, wn cfthesubjectproperty,herebyauthorize �� --T L(
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER`OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
L,goritailtod,nithis application is true and accurate to the best of my knowledge and understan)in7i /y
Print[ 4�e &Authiorzed Agent's Name(Electronic 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.eov/oca Information on the Construction Supervisor License can be found at www.mass.cov/dos
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.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"may be substituted for"Total Project Cost"
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