3 CRESCENT DR - BUILDING PERMIT APP e
� The Commonwealth of Massachusetts 11III�SPECTIONALS RVIDF
Board of Building Regulations and Stand;
Massachusetts State Building Code,780 CMR SALEM R�ys Iar 2011
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Building Permit Application To Construct,Repair,Renovate 1 h a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number. I Date Applied:
0%
Building-official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
�3 C'✓eSrP✓J4 �r,
Lla 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 H) Frontage(It)
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❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Ali ko cab; �Sa /em Mao1970
Name(Print) City,State,ZIP
,3 q72-7tio - 9%5.6
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check sH that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief-D,escr/iption of Proposed Work`:
✓LF.Z�It el.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1.Building $ '7 y G,no 1. Building Permit Fee:$ Indicate how fee is detemained:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(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: $ 76114
6yG 00 ❑Paid in Full ❑Outstanding Balance Due:
.10 I Z 3 5E7v r -To �M • D R , �i �
SECTION 5: CONSTRUCTION SERVICES
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5.1 Construction Supervisor License(CSL) ('SSL-/0 e J�/s//6
1 Q M a 6 N O/•C License Number Expiration Date
Name rofCSL Holder 0 S 1 jt U'l,!r --
List CSL Type(see below)
No.and Street r Type Description
O Q 0 p✓S,_ � O ' O 6 U Unrestricted(Buildings u to 35,000 cu.ft.
J R Restricted I&2Famil Dwelling
Cityll�ow ,State,ZIP !,
M I Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Insulation J
Tele hone Email address Demolition
5.2 Registered Home Improvement Contractor(HIC)
A m Q rl t QN poor 1 Ca//hc/o J HIC Registration Number Expiration Date
HIC Compan Name or HIC Registrant Name
8 •k/ A✓e
No.and Street
a U 0 t/.S /Ne O /9 06 Email address
Ci Mate,ZIP Tel hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(q)
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 (A�r //14 wre4[ L 0. .t o /S
to act on my behalf,in all matters relative to work authorized by this building permit application.
Ali ko La-4 i o //y
Print Owner's Name(Electronic Signature) Date
rin
ECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
me below,I hereby attest under the pains and penalties of perjury that all of the information
plication is true and accurate to the best of my knowledge and understanding.
J,� /0thonzed Agent's Name(Electronic Signature) Dale
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
www.mass.gov,oca Information on the Construction Supervisor License can be found at www.mass.gor=/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 haWbaths
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"
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