12 COUSINS ST - BUILDING PERMIT APP (003) 52q Zo
The Commonwealth of Massachusetts
1, Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
01-DS•h}
Building Official(Print Name) SignalutoDate
SECTION 1:SITE INFORMATION
1.1 Prope Jd�ess: 1.2 Assessors Map&Parcel 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 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
2.1 Owner of Record:
SECTION 2: PROPERTY OWNERSHIP'
Xqint %r—r,i I_C76-4l ,' Sei1(-'YA All L9l 9'7p
Name(Print) City,State,ZIP
o.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number ol'Units_ Other ❑ Specify:
Brief Description of Proposed Work': k
� CUB
SECTION 4:ESTIMATED CONSTRUCTION COSTS
t Estimated Costs:
Item Labor and Materials) Official Use Only
1.Building $ tni, CI) 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $
❑Standard City/Town Application Fee❑Total Project Costs(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full 0 Outstanding Balance Due:
F
SECTION 5: CONSTRUCTION SERVICES l J
0
5.1 Construction Supervisor License(CSL) GS;A f 05 %00 :� 7 /_
6jhq,-Ik5 (�CI �/� License Number Expiration Date 1
Name of CSL Holder
i /J/'C�. Lis[CSL Type(see below)
No.and Street L� Type Description
`1` ��� nA� U Unrestricted(Buildings u to 35,000 cu.ft.
Ci /fown,State,ZIP /U( R Restricted 1&2 FamilyDwelling
ry M Masonry
RC Roofing Covering "
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
C,6io C^a�nz����
HIC Registration Nurnber Expiration
Date
HIC Company Name o HiC Re istrant N e -
i fCi4 �� /-/v Call C�t(Pt��/9 a VqL-
16i
r�
No.and Stree Email ddress
�,ht.��vy tea. y7f 3V1 0277
City/Town,State,ZIP Tel hone
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 /tG'✓'��S ��/,��
to act on my behalf in all matters r Efive to work authorized by this building permit application.
h L2&it�L
[Owner' Name(Elec nic Signature) I D to
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print or Authorized Agent's Name(Electronic Signature) Date
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)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
nL" .mass.gov/oea Information on the Construction Supervisor License can be found at www.mass.eov/dps
2. When substantial work is planned,provide the information below:
Total floor 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"maybe substituted for"Total Project Cost"