21 CROSS ST - BUILDING PERMIT APP (004) eD
'the Commonwealth oftMassagl i►,� !?�1 '
Board of Building Regulation`§`n�i arils CITY OF
"Penn
Massachusetts State Building Code, 780 CM�R $ SALEbI1b��J � A � 4 ' Rev4red,Nrv101/
Permit Application To Construct, Rep} gate Or Demolish a
One-or 7ivo-Family Dwelling
This Section For.Official Use Onl' i ? rer: Date pplled.
� _ �, del-pt.�„ _. " ' L�c✓ .' /.® .
Building Official(Pont Name). - '- Sig`aature�: '- Date
i SECTION 1:SITE`INFORMATION.
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
I.1a Is this an accepted street9 yes no Map Number ' Parcel Number
1.3 Zoning information: IA Property Dl'men Ions: "
" 31F:Y:iV t !p'Vl:rl•i.Ji.'N :t�
Zoning Disuict Proposed Use Lot-Area(sq R) ;}t'n I Fmntager(�tA;.� -
1.5 Building Setbacks(It)
Front Yard - Side Yards - Rear Yard
-Required - Provided Requl d - Provided.: . Required Provided.
1.6 Water Supply:(M.G.L a.40,§54) 1 1.7 Mood Zone Information. 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?POblic 0 Private O. — Check lF _ _ Municipal O On site disposal1. O
SECTION2 PROPI3RTYOWIYERSRfPt'. 'r
2.1 Ownert o Record-
M i t�—
N7 ne( 'nt) City,State,ZIP
No.and Street - Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED)WORW(check all that apply)"
New Construction O Existing Building O Owner-Occupied O .-Repairs(s) t7 Alteration(s) 17 Addition ❑
Demolition O Accessory Bldg.O . Number of Units Otlrer O Speciry.
Brief Description of Propos ork':
SECTION 4:ESTIMATED CONSTRUCTION COSTS-
Estimated Costs:
item OMCInl Use Only
Labor and Materials
I. Building S 1i{S(JTj - 1. Building Permit Fee:f indicate how fee is determined:
2. Electrical S 0 Standard CitylrownAppllcadonFee
0 Total Pmject Cosa'(Item 6)x multiplier x
3. Plumbing I S 2?Qther Fees: S
d.Mechanical (flVAC) S List:
5.\Ucluinieal (Fire 3
Suppress Total All Fees:S
/��p. Check No./23' Check Amount: Cuh Amount:
G.Tutul Project Cost: S y�i-� ❑Paid in Full ❑Outstanding Balance Due:
b�I
r
ECTION5: CONSTRUCTION SERVICES
5.t Constriction Supervisor Licensee"(CSLj s'`+;': g-7
` 1 jl .f' - 'License Number Expiration Date
Name of CSL Holder r't1G G'Jj.
List CSL'rype(see below)
EYID W.l??llll Tyt>e. Description
No.and Street . i IOD ut 0t
U UnresiricteJ BuilJin up to 35,000 cu.R.
Salem Mf1 0070
R Restricted I&2 Famil Dwellin
Cityrrmvn,State,ZIP ` - M 'Masonry
RC Roofin Coverin
WS Window and Skiing
SF Solid Fuel Burning Appliances
q ")�'(- 1 Insulation
Telephone —� Email address ., D Demolition'
I.
5.2 Registered Home improvement Contractor(HIC) lyzos--�) .3
Atlantic Weatheri�atinn i I ! - HIC RegistnitionEspiretian Dnte
HIC Company 99'9ZV&silhisWV_Y44MName
Ue
No.and Street '(MA,U IV 1U Email address
City/Town. State ZIP Telephone
SECTION 6r WORKERS,.COMPENSATIONINSURANCEAFFIDAVPiF(M:G,L c.15i§2$C(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 Isluance o a building permit.
Signed Affidavit Attached? Yes.......... No...........O
SECTION7a OWNERAUTHOIHZATIONToBECOMPLETEDWHEN' ?,"
OWNER'S AGENT OR CONTItACTO1LAPPLIEH FOR BUILDING
PERbiI F'
1,as Owner of the subject property,hereby authorise
t9 act an my behalf,in all matters relative to work authorized by this building permit application.
t
M�1(� Date
Print Owncr's Name( eeilmnic Signature)
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,)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 Owner' r r u brio At nic Signature) ' Date'
NOTES:
1. An Owner who obtains a building permit to Jo his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program);will nu have access to the arbitration
program or guaranty fund under M.G.L.c. Ia2A.t terimportant mformafion on the HICYrogram can betordT
wow mass.cov,'oca Information on the Construction Supervisor License can be-round at+vww.mas.��ov;dos .
t 2. When substantial work is planned,provide the information below: -
Total floor area(sq. ft.) '} (including garage,finished basementlattics,decks or porch)
Gross living area(sq. R.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halflbaths
'type of heating system Number of decks/porches
Type of cooling system Enclosed Open
.i. "Total Project Square Footage"may be substiuted for"Total Project Cost"