27 CROSS ST - BUILDING INSPECTION (� The Commonwealth of Massachusetts ''"' ' tU F,a(p
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR ZUIb OCT 1 S �j�'1
AsekIhFEBO!!
I Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Tivo-Fmnily Dwelling .
This Section For.Otf(cial Use lZal
Building Permit Number. Date: pied
1.4
�o
Duilding Official(Print Name).- Sig(tatuR•: : :- - Date
SECTION 1:SITE INFORMATION.`
I.1 Property Address: 1.2 Assessors Map Rr Parcel Numbers
. 62:7 Crass Y-/-.
1.to Is this an accepted street9 es no Map Nombe,, A - ;a
1.3 Zoninglnformation: 1.4 PropertyiDlmenslgnsar:fill, '; 1t}
Zoning District r Proposed Use Lot Area(sq R) f^Flodinge(it)
Building Setbacks(R)
Front Yard Side YardsRear Yard
Required provided -RequiredP.rovided. .Requited .. .. Provided
1.6 Water Supply:(M.G.L a 40,§5d) 1.7 Food Zone Information: 1.R Sewage Disposal System:
Public O Private O.- Zone: _ Outside Flood Zone? Munici al O On site di sets diem O
Check if esO....- P y
' ? SECTION2. PROPERTYOWNERSHIPk `
2.1 owner'of Record: QQ
6Demolltion
city,Swm,ZIP
Telephone Email Address �f:J�%\
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check sltthat apply)
ion t] Oickfing Building❑ OhOcuidAddition❑O Accessory Bldg.C Number of Units_ Other especlty; GViiY oti o
Brief Description of Proposed lVorkr:
z Ti C _,-
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Niaterials Ofl(cful Use Only
I.Building g 1. Building Permit Fee:$- Indicate how fee is determined:
2.Electrical s O Standard CilyNown Application Fee--
❑Total Project Cost-'(Item 6)x multiplier x
3.Plumbing s ? Qther Fees: S
4.ilcchanical (FIVAC) s List: n�
5.Mechanical (Fire
Su ression) s Total All Fees:S
G.Total Project Cost: s Check No._Check Amount: Cash Amount:_
6l/Lh• ❑Paid in Full 13 Outstanding Balance Due:
l �l � rnrAtt,'��b -3-bG , c . INj ,
SECTIONS: CONSTRUCTION SERVICES
5.i Construction Supervisor License(CSL) V 7 ?7-7 (4 l Z 3{/
r• --, LicenseNu� ExpiraliunDate
-
Name of CSL Holder EC14 W.Paltll ListCSL'fype(see below)
q TJiltMQ''t!pt Tye Description -
No.and Street Salem Mtn 0070 U UnrestriUed Buildin u to 35,Ou0 ca.R.
R Restricted 1&2 F unil Dwellin
City/I0% State,ZIP M Maso
.. RC Rootin Covcrin
WS Window andSidin
Sf Solid Fuel Burning Appliances
q,-7 Insulation
Tele hune Email address D Demolition
5.2 Registered HomeImprovement Contractor HIC) if Z o s, 7 l /
Wwtbt 8lIm L HIC Registration Number Expiration Date
1IIC Company Name _
Email address
No.mid Street .
Tet om
Cityrrown,State ZIP « -
r ' s
.0 E AFFIDAVIT(dLG L w e. l5i§25C(t7}.
SECT[ON 6:�VOR(CE RS.CObIPENSATIO N 1u1V . RAN(
Workers Compensation Insurance affidavit mist be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Isl;uance 0JAhabuilding permit.
Signed Affidavit Attached? Yes.......... No...........l7
SECTION7az0WNERApTHORIZATIONTOBE-COMPLETED,WHEN?.
OWNER'S AGENT OR CONTRACTORAPPGIEg FON BUILDING.PERMIT'
i,as Owner of the subject property,hereby authorize
tg act on my behalf,in all matters relative to work authorized by this building permit application.
Date
ennt Ow er's Name(Electronic Signature) _
SECTION 7b:OWNER'ORAUTHORIZED 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
it AJ
Print Owners or r utlmrized r t e(•lectronic Signmure)
Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
- - - -
knot registered in the Home Improvement Contractor(HIC)Program):will> have access to the arbitration Tar
program or gunranty Pond under M.G.L.c. 142A.00 fii er Important information— on We HICYrogram can e o
wwty m:us.cov:!oca Information on the Construction Supervisor License can be.found at wvvw.mass.eov!duS .
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) N .(including garage,finished basement/attics,decks or porch)
Habitable room count
Grass living area(sq.ft.)
Number of fireplaces Number of bedrooms
llis
Number of bathrooms Number of deckst pat
Type of heating system Number of Jecksl parches
Enclosed Open
Type of cooling system
"Total Project Square Footage"may be substituted for"Total Project Cost"
). �t 1 S