10-12 CUSHING ST - BUILDING PERMIT APP The Commonwealth of MassachusettsCE VICE
Board of Building Regulations and Stand ��AL SER CITY OF
ALEM
Massachusetts State Building Code%%VE SdMar
(� n y evised tti/ar 201!
r Building Permit Application To Construct, Repair, RenovaotTr' Fsh
One-or Two-Family Dwelling TO
,1 This Section For Official Use Only
^'y Building Permit Number: I Date Applied:
Building Official(Print Name) 'Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
taJ ,ICShi� o
I.la Is this an accepted street. yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L a 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: Outside Flood Zone?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 wner of R rd.
Name(Print) �Ciity,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) Zi Addition ❑
Demolition ❑ Accessory Bldg. ❑ [Number of Units Other ❑ Specify:
Brief Description of Proposed Work': 1, '
O e L
JXA AA-AV yr z~,
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2.Electrical $ ❑Total Project Costs(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 1( (9,ce3 ❑Paid in Full —70 Outstanding Balance Due:
1"lAIuem ill 1
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
`QS1?33 S
t—t� License Number Expiration Date
Name of CSL Holder
I!e 1V t ' List CSL Type(see below)
No.and Street rl{� hype Description
Sa /I'IAff �-�� U Unrestricted(Buildings u to 35,000 cu.ft.)
R Restricted I&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
�-7 0 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improve nt Contractor(HIC) , u , (A u 9 _
+ IBC° HIC Registration Number - Expiration Date
H1 1 75 V 0
NP.
✓ HIC Regis ant Name
•and Street ' Email address
V-% M* o cn Al o g78- 7yr -okya-J
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(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 Issuan e of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize
to act on my behalf, in all matters relativeto work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contat Vinis Ralic'tion is true and accurate to the best of my knowledge and understanding.
Mat wnei s or Autho zed Agent's Name(Electronic Signature) Date -
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 can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dips
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.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'