12 CONNERS RD - BUILDING INSPECTION 505�� P to �/J o
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR,7'"edition Ois SALEM
- Revised January
Building Permit Application To Construct, Repair,Renovate Or Demolish a !, 2008
One-or Two-Family Dwelling
IXThis Section For Official Use Only
Building Permit N b Date Applied:
Signature:
Buildi ommissi r/Inspector of Buildings Date
SECTION l:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1 Conn ?i r RO/
L la 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 ft) 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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Nam t) Address for Service:
S Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ 1 Repalrs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work'-:
,Z;w h.ew
m `
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: P 00 M Official Use Only
Labor and Materials i
1.Building $ L Building Permit Fee: $ Indicate how fee is determined:
�C)a 7 ❑Standard City/Town Application Fee
2.Electrical $ � ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ O/! 00 2. Other Fees: $
4.Mechanical (HVAC) $ c�- List:
5.Mechanical (Fire
Suppression) $— --- Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 47 S1571�� (2�7 0 Paid in Full 0 Outstand' g Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 2-71gy/ �JS'_"S-12P/l
on,-)i l e-/ f- zrog! loznr- License Number Expiration Date
Name of CSL-Holda
Ja/ Lim List CSL Type(see below) (/
Aaa,e„ii 1'r fvvra_-A�-. /nA olgV' Type Description
—�� U Unrestricted(up to 35,000 Cu.Ft.)
R Restricted 1&2 Family Dwelling
Signature9l�9� M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
_ D Residential Demolition
5.2 Ijggistered Umne Improvemen Contractor(HIC) /S—Q3 i/n
J Gn�'z/ ,J�/a¢rOP9�Dt/J� / 7
HIC comp, y N ante or C Registrant Name Registration Number
V/ �
F�1Ameo� fJvQ rwc ��✓�o ,///�, 0/40� �y aY -�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, C (2r 1^ nG e e— La,�, r�_,^�� as Owner of the subject property hereby
authorize n�ir . �/ J�i�.ero.�o7oUd-- to act on my behalf,in all matters
relati r to work authorized by t6is building permit application.
3
ature 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
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of 'u )
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 not 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 780 CMR Regulations I IO.R6 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"