8 CHEVAL AVE - BUILDING PERMIT APP � 1
The Commonwealth of Massachusetts — - — ---- —
�� ;I'1 Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code. 780 CMR SALEM
'L,�d Xerised.1lar 1111/
Building Permit Application To Construct, Repair. Renovate Or Demolish a
One-or Two-Fawily Duelling
This Section For Official Use Only
Building Permit Number: a!p Applie :
Building 0111 al(Print Name) Wature Date
SECTION l:SITE INFORNIATION
1.1 Property Address: 1.2 Assessors Nlap&r Parcel Numbers
��rvUE
I.Ia 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 fl) Frontage(11)
I.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.1-c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if yesp Municipal❑ On site disposal s)stem ❑
SECTION 2: PROPER OWNERSHIP'
.1 Owner'of Record:
l2E(rOlt -F IAvtse A— Ae7, t se\,2uti M ONa
ame(Print) City, Late.ZIP
8 CAGNi t` PNl k-?C 7 osz gr�n�eAW.1� Verrl2am. eA-
Nu.and Street - 'relephune Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ AIteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work:
SECTION 4: ESTINIATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1. Building S b pod-00 1. Building Permit Fee: E Indicate how fee is determined:
2. Electrical gStandard City7own Application Fee
a�8 CoC7D ❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S ) ppp .00 ?, Other Fees
4 Mechanical (IiV.\C) S List:
5. Mechanical (Fire
Suppression) Total ,\II Fees: S
Check No, Check Amount: Cash Aniounl:
G. Total Project Cost: S �9 �O ----- ------
I 13 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
Liana Number I(spiration Date
Nance ol'C'SI_ Ilulder -- —— ---
List CSL I)pc(see below)
No.and Street Type Description
U Unrestricted IlkiilJin s u' to 35,000 cu. tl.)
R Restricted 1&2 Family Dwelling
Cit,v fown,.State.ZlP M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fucl Buming Appliances
I Insulation
Telephone Email address U J Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Registration Number F...piralion Date
I IIC'Company Name or I IIC'Registrant Name
No.and Street Email address
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 .......... 0 No...........❑
SECTION 7a:OWNER AUTHORIZATION TO HE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the property,hereby
authorize
J P Y
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�' 'ng name be ow, I reby hest under the pains and penalties of perjury that all of the information
co to din 's appIle it
is a an ccurate to the best of my knowledge and understandin
1Z
Print Owne nt's Name jr.ttetaiic.Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Hume 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
(A.0 Information on the Construction Supervisor License can be found at q�� .nl:us.guy'Jps
2. When substantial work is planned, provide the information below:
Total Boor area(sq. R.) _(including garage, finished basentent'attics,decks or porch)
Gross living area I sq. R.)_ Habitable room count
\'umber of fireplaces___ — Number of bedrooms
Namher of bathrooms _ \'umber of halfb:nhs __
Number of decks, porches___ _-- —---
F)peofcoolinassstenl _ EncloseJ ,______--_--- Open
3. "foal Project Square Footage"may be substituted for"rotal Project Cost"