23 CROWDIS - BUILDING INSPECTION e�D 01-4-4 S?"Y e
The Commonwealth of Massachusetts
y J } Board of Buildipg.Regulations and Standards CITY
a OF SALF.M
Massachusetts State Building Code, 780 CMR , ,(Jltton
i � , , �J � i Revised Jmruury
Building Permit Application To Construct, Repair, Renpvalg(dFP�5molish a 1. zoos
IOne-or Two-Fumi! writing
This Sect' or 0 cial Use Onl
Building Permit Number: a Appji
Signature: 7/
Builaing Commissi nspecloro Date
SECTION 1:SITE INFORMATION
1.1 Prro�per Aldress: 1.2 Assess rs Map& Parcel Numbers
Lis Is this an accepted street?yes no Map Number
1.3 Zoning Information: 1.4 Property Dimens)au
Zoning District Proposed Use Fo Area(sq 11) Frontage(tl)
1.5 Building Setbacks III)
Fmnt,Yard-- Side Yards - Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Floo6:Zooe Information: 1.8 Sewage Disposal System:
Public❑ Private❑- Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
'Check-if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Own r'of Record•
Rio h,Io ou (as 23 C(-ovJdiS SF
Nume(Print) Address ror Service:
:<=°"�4 5D�� — 9�- 3 2
SignWu tr Telephone --
SECTION 3: DESCRIPTION OF PROPOSED WQRK�(c6eckp1l ah�Mpply)
New Construction❑ Existing Building O Owner-Occupied O Repairs- 0'f Alteration(s) ❑ Addition ❑
Demolition ❑ AccessoryBldg.0 Number of Units_, <Other O, 51>fcify:
Brief Description or Proposed Work': 6 ja S ea. 61
q.
i
SECTION 4 EST.IMATED CgNSTR"11'-4ON'a X
Estimited Costs: y `
Item Of11ch1 Use-Only
' Labor.anJMiteribls �: ,: . .,.. ,. < ...,-. ,. -
I. Building s I. Building PermitFee s. ~lndicate`howl'ee:isdetermined:
�. Electrical S O Standard City/Town Application Fee
❑TotaIProject Cost. (hem 6)x=multiplier x
3. Plumbing Is 2. Other Fees: 5
'4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:$
Check No._Check Amount: Cash Amount:
6. Total Project Cost: s ��Q G1OPaidinFull 0 Outstanding Balance Due:
SECTION 3: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervlsor(CSL)
'e W.Palm License Number tis i lion Date
Name ul'CSI.• Ilulder
3iaTi t ListcsL ppe(+eeb:low)
r Description
Address _ U I t)nrestricted(up to35,000 Cu.:Ft.
/�j R Restricted IR2 FamilyDwelling
t
Signature �iy'. M al nly
�!� RC Residential RootingCoverin
fclephone //' WS I Residential Window and'Stdin ._
7 y /_g y 3 SF Residential Sulid Fuel Btirrtin A"`fiance installotim
'1 D Residential Demolition.
55.2 Re�Istered Home Improvement Contractor q�o fir'
II IIC Com ap� e i•tr OR egistration Number
pit J W"" allQ AVCIRIC
Address MA 0197Q- 9-7� y-jj!V7 Expiration Date
tilgnalYre A/ Teleplumc ..-.-
1 �!
SECTION 6: WORKERS' COMPENSATION INSURANCEAFFIDAVIT(M.G.L c.152.1_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 Issuanc f the building permit.
Signed Affidavit Attached? Yes .......... No...........13
SECTION 7a:OWNER AUTHORIZATION TO`BIC COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, A-�`f k u..i J y1 o- n i Oao,, 1 a S as Owner of the subject property hereby
authorize_� n �� to act on my behalf,in al matters
relative to work authorized by this building permit application. I
Si tureof Owner . Date.
/SECTION 74:;OWNERt OR AUTHORIZED AGENTpEC,LARATION.
Fer [� as Owner or'Authorized'Agent hereby declare
fthe.statements and information orrthe foregoing application are true and accurate,to the besenfmy knowledge and
behalf
prim Name
Signature ot'Owner or Aulhonzed nv;nt Dale
Signed under the pains and 'nahies of p 'u- y
NOTES:-
1. An Owner who obtains a'building permit to,do his/her.cwn work,or an ownerwho him an.unregistered contractor
(not registered in the Home Improvement Contractor(HiC)Program),will gi�(have access to the arbitration
program or guaranty fund under M.G.L. c. 1 J2A.Other important information on the HIC Program and
Construction Supervisor.Licensing(CSL)can be found in 780 CMR Regulations I I O:R6:and 110A5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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" may be substituted for"Total Project Cost"