15 COLBY ST - BUILDING PERMIT APP (004) C �i1�
c, a The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 C•MR, 7"'edition OF SALEM
I Hecise<l Jwar�rrt•
1 i Building Permit Appl' ation o Construct, Repair, Ren ate Or Demolish a 1, '008
IOne-a Tiro-Family Drve!!ir
Thi Section For Of1ic' Use Only
Building Permit Nu mbe :
D Aplied: Z t 0
Signature: lq
BuildingC n f Buildings Date
S CTION 1:SITE INFORMATION
. Prope y cidress: 1.2 Assessors Map& Parcel Numbers
i� �olbc�
I.la Is this d street?yes_ n✓ o Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
/_oning District Proposed Use Lot Area(sq 11) Frontage(R)
1.5 Building Setbacks(it)
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? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑ F P y
SECTION 2: PROPERT WNERSHIP'
Owner'of Record:
(� 0. Let t e /s" Co 1bv
Nam rint) Address for Service: ��—
[/ 778 7 L11 O r7 4 1�(
Signature IF Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number-of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
n dt ( t✓ tL 5 r
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1. Building $ I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost' (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
q. Mechanical (11VAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S G`j 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES w
5.1 Licensed Construction Supervisor(CSL)
I.iccnsc Number Expiration Date
Name of CSL. I[older
List CSL Type(see below)
T." Description
AddressIl UnrestricteJ(up to 35:000 Cu. Ft.)
It Restricted l&c2 Family Dwelling
Signature M Xlasonry Only
RC Residential Roulling Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
11IC Company Name or HIC Registrant Name Registration Number
Address
Expiration 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, 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.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
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
be If.
4Lei✓ f�
Print Nam
Signature of Owner r Authorized Agent Date
(Signed under the pains and penalties of eriu
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 Prot 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 730 CMR Regulations I IO.R6 and 110.115, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basementlattics,decks or porch)
Grass 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 he substituted for"Total Project Cost"