7 CUSHING ST - BUILDING PERMIT APP (002) IL. The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR,71s edition OF SALEM
Revised January
Building Permit Application To Construct,Repair,Renovate Or Demolish a 1,2008
One-or Two-Family Dwelling
',":This Section For Official Use,'Only,
.
Batldmg`PernutNn,� D�teApplied
7 Tv
'signature
; '. `Baildmg Com�iiissroneU- pector of�uilumge " Date•""f �`a,P 'd' ' � ' ,'+ ;
.,;aSECTI0>`11:SITE INFORMATION �. � '
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
7 t"tJSf/I/t/� 5; -
1.1a Is this an accepted street?yes t/ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(it)
1.3 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 03' Private❑ Zone: _ Outside Flood Zone? Munici
Check if yes❑ Pal Er&site disposal system ❑
$ECTION,2: PROPFRTYOWNERSIllPI
2.1 Ownerr of Record:
E/C .T"Vere +i T/L rf !°GSNiN� 5' S�9(vr YI1 /}
Name(Print) Address for Service:
Signature Telephone
SECTION 3,DESCRIPTION OF.PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building WJ Owner-Occupied aYJ Repairs(s) ❑ Alteration(s) 11Y Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Specify:
Brief Description of ProposedWork2: .yNS'TllLc {ji4'7WItaUa
T' SECTION 4:ESTIMATED CONSTRUCTIOPf COSTS
Item Estimated Costs:
(Labor and Materials , � * r OP[icial Use Only
j d M �,-, 5
1.Building $ SL, 1 0 O Building PetmtfFee $ " °'"*' Indicate how fee is determined:
2.Electrical $ a U G t3 Standard Cttyl1Town Application Fee-'
p Total Project Cpst'(Item 6)x multiplier x
3.Plumbing $ 3 Sz' 0 i,2. OthedPees: V
4.Mechanical (RVAC) $ Ltst `
5.Mechanical (Fire
$ Total hll Fees $Suppression) °
G j 0 U CheckNp Check Ainaunt CashAmdunt
6.Total Project Cost: $ / ❑pa,d in Full O Outstanding Balance Due:
SECTIONS: COIYSTRUCIIOlYSERVICESr x
5.1/Licensed Construction Supervisor(CSL) Fr ��/U
/C 0�tow y- A- �j-�j License Number Exp ration ate
Name of CSL-Holder /!an/iFR List CSL Type(see below)�TypeD _
� .�� Description
U Unrestricted(up to 35,000 Cu.Ft.
� R Restricted l,&2 Family Dwelling
rgoature M Masonry Only
971-17yy 70 a O RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 R�gg�sgte�red Home Improvement Contractor(HIC)
A/I14-W9v%E d SUNS C�G.yT/IACy/•yG �iyG / y�18�J
HIC Company Name or HIC Registrant Name Registration Number
,AU )Ao&.Alf6) 57- of- ZW4
_;7 ration Date
Signature Telephone
SECTION 6 COMPENSA WORKER5 TION INSURANCE AFFIDAVI C(M G.L:c:152.§ 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 of the building permit.
Signed Affidavit Attached? Yes .. .❑ No...........❑
SECTION U:OWNER AUTHORIZATION`TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
rA/6-eM 'S L, as Owner of the subject property hereby
authorize i90 6e2 'r AICS&AN 4-t l F 1,41e A,1W1C f to act on my behalf,in all matters
relative to work authorized by this building permit application.
_ X/r1Z)
Signature of Own Cr Date _
SECTION 7brOWNEIV_OR AUTHORIZED AGENT DECLARATION m
I, 4///orn r Q/rl�/lii9//l4, as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature o Owner or Authorized Agent Date �
Si ed under the ins and nalties of
" �.� ii �.,.-t -r 75 . 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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,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'