41 COLUMBUS AVE - BUILDING PERMIT APP (003) GK �Q lZ
The Commonwealth of MassaMIVED
Board of Building Rego 14NUEiMONMoSERVICES CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,lilk-,SEW4ntvaAC12DKlish a
One-or Tivo-Family Dwellit g
This Section For Official Use Only
Building Permit Number: Date Ap d:
Quilling Official(Print Name) Signature Da e
SECTION 1:SITE INFORMATION
1.1 Property r II re,FS,"7 1.2,kssessors iYlap 3r Pareel Numbers
1.1a Is this an accepted street?yes__,_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
zoning District Proposed Use Lot Arcu(sq ft) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(NI LG.f,c.•10,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ zone: — Outside Flood Zone?
Check if yesO Nlunicipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'o corl
�l.b_�_—
Nome(Pritrt) Cily�l''
No.and Street Telephone [..'mail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check a rat apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other ❑ Specify- _
Brief Description of Proposed Work`:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Ose Only
I. Building $ I. Quilding Permit Fez: $_ Indicate how fee is determined:
2. Electrical $ ❑Standard City/town Application Fee
Cl Total Project Cost'(Item 6)x multiplier x_
3:Plumbjng $ 2. Other Fees: $
4. Mechanical (IIVAC) $ List:
S. Mechanical (Fire _ _ --
Su ression) $ Total All Fees:
�7 6. Total Project Cost $ Check No. _Check Amount: _Cash Amount
❑ Paid in Full ❑Outstanding Balance Due:
SCUT Tb [A- D . CAT
SECTION 5: CONSTRUCTION SERVICES r
i
5.1 Constructio�'�/7�nern r License(CSL)
Vl f� � 'met License s umber Erpi a[i Date
Name of CSL Hol cr
ze '- ) q]7 List CSI.Type(see below)_
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu. 11.)
R Restricted 1&2 Farnily Dwelling
Qlyllown,`State,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Soli)Fuel Burning Appliances
I Insulation
'fete hone Email address D Demolition
5.2 Registered dome 1 t rover ent Contractor(F IC)
IIIC Registration Number Ex im on Date
MCC 1 o -lC amc
No., ' r e ,�
c I� Email address
Cit /' own, Slate, IP ?`� telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G,L.e. 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 AUTFIORI'LATION 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 pcion.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering e below, I hereby attest under the pains and penalties of perjury that all of the information
contained in t is ap is tion true and accurate to the best of my knowledge and understanding.
Print Owner's o or zcJ gents Name(Electronic Signature) U c
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) Pro.gram), 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.gov/oca Information on the Construction Supervisor License can be found at www.ntass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage, finished basement/attics,(leeks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms _ Number of halt/baths
Type of heating system _ _ _ Number of decks/porches
Type of cooling system__ Enclosed Open
3. "r t al Project Square Footage"may be Substiarted for"I'(tilh roject Cost"