27 CROSS ST - BUILDING INSPECTION (2) 2' ' f2 to
�k
The Commonwealth of Massachusetts ITY OF
Board of Building Regulations and Standards 2Q1b DEC 8 RAM00
/ Massachusetts State Building Code, 780 CMR
0 ReviseJ:t/ur2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family y Dive""'g
This Section For Official Use Only.e.':. ` 'r ,..`^
Building Permit Number. Dat "Applic f V. a _ L
Date
Building Official(Print Name).
SEC IiuNI:SITE'INFORM[ATION` `
1.1 Pro: Address: s� 1.2 Assessors Map&Parcel Numbers
�'t�ss
I.1a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 'Zoning Information: IA Property Dirnenalonksv oti1L^3' yr lr){ !ti➢C,
Zoning District Proposed Use Lot Area(sq tl) Frontage It ° �'
la Building Setbacks(R)
Front Yard TYards Rear Yard
Required Provided Requireided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zn: 1.8 Sewage Disposal System:
Zone: _ one? Muniei 1 O On site dis osal s stem
Public O Private O Pa p y
SECTION2: PROPERTY OWNERSHIP!`
2.1 07nertofRecord:
fnAV,i(ASt 6 arcZr t K
R me(Print) City,State,ZIP
a-) Cuss 9
No and Street Telephone Email Address
SECTION.3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction 0 Existing Building 0 Owner-.Occupied ❑ Repairs(s) 13 1 Alteration(s) ❑ Addition ❑
Demolition O 1 Accessory Bldg.❑ Number of Units_ Other O Specify:
Brief Description of Proposed Work':
SECTION'4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1. Building 5 3 .- 1. Building Permit fee:S Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical 5 0 Total Project Costs(item 6)x multiplier x
3.Plumbing S 2. Other Fees: 5 ^ /
4.Mechanical (lIVAC) S List: bpi
5.t',Icc=al (Fire 5 Total All Fees:5
Su ression)
Check No.1296SCheck Amount: Cash Amount:_
6,Total Project Cost: ❑paid in Full ❑Outstanding Balance Due:
\-21 I (_1A L5_--'O -M G C .
SECTION 5: CONSTRUCTION SERVICES
5.i' Coristructioo Supervisor License(CSL) 5797-7
License Number Expiration Date
Name of CSL Holder List CSL Type(see below)
Eric W. Palm Type Descriptioe
No.;md Sued OII U Unrestricted(Buildings
u to 35,000 a. It.
Salem, MA 01970 R Restricted 1�2 Famil Dwellin
Cityfrown,State,Zip M masonry
RC Roofin Coverin
WS Window and Sitting
G SF Solid Fuel Burning Appliances
7$.7gtf- S-1 I "
Tcle hone - Email address D Demolition
5.2 Registered Home improvement Contractor(HIC) 6 zat? 3//Z 8
Atlantic A e�aethe172atr4l�OR.i i HIC Registration Number Expiration Date
HIC Company Nan ag1J11C nORte
No.and Street Salemg WA 0 Email address
Ci /town State ZIP Telephone
SECTION 6:WORKERS'.COIVIPENSATION INSURANCE AFFIDAVIT(M:G L.a I52.$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 oft building permit
Signed Affidavit Attached? Yes .......... No...........13
SECTION 7a:O�YNER AUTHO.[tIZATION TO BE.COMPLETED WHEN'
OWNER'S AGENT Olt CONTRACTOR:APPLI"FOR BUILDING.PERM r
1,as Owner of the subject property,hereby authorize (f I C6/H-7
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Muni ' �o ,f� • �� I Z/7
Print Owner's Name(Electronic Sr ore) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
cotrtaitle this 1pplicationw4rue and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who lures an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will nor 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 nuw,aov'oca Information on the Construction Supervisor License corn be found at w�aw moss.�oe'J=_Lis
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. It.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Numberof h:dtlbaths
Type of heating system Number of decks/porches
rypeorcoolingsystem Enclosed Open
1. "Total Project square Footage'may be substituted for"rota)Project Cost"