30 CHARLES ST - BUILDING PERMIT APP ["lie Commonwealth of Massachusetts CITY OF —
Board of Building Regulations and Standards SALENI
Massachusetts State Building Code, 780 CMR Revised.tlar 01
L
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fumih Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied: _
r
Building Otf 4
1(Print Nam•) S' nature Date
i ECT N SI NFORMATION
1.1 oper Address: i'� 1.2 Assessors N1ap& Parcel Numbers
I.I a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Toning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yurd
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? Municipal ❑ On site disposals)s stem ❑
Public❑ Private❑ Check if yes❑ P P >'
SECTION 2: PROPERTY OWNERSHIP'
2 caner of d: � �/9 2
N:une(Prinlr City,State,ZIP t� �1s ' �,�� ^� /
No. and Street 'telephone 4 ?Em.•lfl Address
SECTION 3: DESCRIPTION OF PROPOSED WORK*(check all that apply)
New Construction ❑ Existing Building ❑ Owner- ccupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ nmber of Units_ I Other ❑ Spccily:
Brief Description of Proposed Work-:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
'_. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $
q. Mechanical (IiVAC) S List:
5, ,Tledmmmienl (Fire $ Total All Fees: $ —
Su ttcssion)
C'hcck No, Check Amount: Cash :\mount:_____
6. Total Project Cost: d�0 ❑ Paid in Full 0 Outstanding Balance Due:
SEC,['ION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
-- License Number Ispirtlion Date
Name of CSI- I IulJer
List CSL f)pe(sec below) _
Nu. :utd Street -- Type Description
U I Inrestrictc to 35,000 cu. fl.)
R Restricted I$? I... Da-ellin
Cilylfuwn. Slate.ZIP M Mason
RC Roollti," verin t
WS Window and SiJin
SF Solid Fuel Burning Appliances
I Insulation
'fete hone Entail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I IIC C ompmty Name or I IIC Regislrunl Name
No.and Street
Email address
City/Town, State,ZIP 'relc hone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 .......... O No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property, hereby authorize
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: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below. I hereby attest under the pains and penalties of perjury that all of the information
containe ii is application is true and accurate to the best of my knowledge and understanding.
t nn ner s orn.ulhonzcJ Agcrit s Name(Electronic Signulurc) Dula
NOTES:
7%Vhen
er who obtains a building permit to do his%her own work, or an owner who hires an unregistered contractor
stered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
or guaranty fund under I.G.L.c. 142A. Other important information on the HIC Program can be found at
).s.�y%.oc,i Information on the Construction Supervisor License can be found at t�ww.n is is. nit 11p,
bsLvttial work is planned, provide the infoea(sq. It.) (including garage, finished basentent'auics,decks or porch)
rossvngarea(sq. it.) _ Habitable room count
Number of fireplaces- -_-- Number of bedrooms ---
Number of balhroonts__-----___--_ Number of halfbaths ------
1)lie of heating systein. - —
N ----
umber of decks,porches_
1}peufcoolingsystent -en -------
- -- -...--------- Enclosed _ open
3. "rot;d Project Square Footage"may be substituted for"rota) Project Cost"