17 CUSHING ST - BUILDING PERMIT APP (002) ` X/ , The Commonwealth of Massachusetts
�( CITY OF
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR SALEM
fir! Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit N ber: �: " ° Date App ed:'
'nuifding Offi iat(Pont Nano ,�. ignatur
t SECTION 1: SITE INFORMATION - Y
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
X 11 rat o Qr)
1.1a 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 c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
" SECTION 2- PROPERTY OWNERSffiPi. ,
2.1 Owner'of Record:
X 1' nt)ftNState,
111fl [�1�I�7�
Name(Print) � City,State,ZIP
x h (°A1c11t N— X611 Igi 39fo
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ I Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory" Bldg. ❑ Number of Units Other ® Specify:Inculation
Brief Description of Proposed Work : Walls
_R15Cv- .mac, -oAoirr-selallien Weatherstripping
an e� ttl r weatneri'zanon measures t �
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: s
F3
Item Labor and Materials .. ' 'r ,. Official Use Only s
1.Building $ X .Lp �(�(;� . "1 1 Building Permit Fee: $ ' .S Indicate how fee is determined:`
❑Standard�City/Town'Application Fee
2.Electrical $
❑Total Project Cost (Item6)x multiplier ate+:: x
3.Plumbing $ 2 ,Other'Fees: $
4. Mechanical (HVAC) $ List: �!1
5. Mechanical (Fire
Suppression) $ Total All Fees:
ff� Check No Check Amount: Cash Amount:
6. Total Project Cost: $ x .(p i(FLN V I ❑Paid in Full ❑ Outstanding Balance Due:
� iA �
SECTION 5: CONSTRUCTION SERVICES14
5.1 Construction Supervisor License(CSL) ,p,6z J I Ll I3
) SC SUM( y,g License Number Expiration Date
Names of CSL Holder �.,\ 1' List CSL Type(see below)
`),l W M111 Vf\ ACT No and Street Type Description.'. _
�� n PUAV, m w� 2)v U Unrestricted(Buildings u el ing cu.ft.)
W� i R Restricted 1&2 Family Dwelling
City/To ,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Q� I Insulation
Tee hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) I U3 1 O 6 ,� 1 i
I 9AIf (AV) ( 6q\r ,i 1'� oAn(�;( IP,A HIC Registration Number Explratioh Date
H ^Company Name or HIC Registr
No.d Street T�1 S Email address
�(�, �� JS
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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... Q 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 autborize,�=- 5ft N(US—American Building_TPchnologie
to act on my behalf, in all matters relative to work authorized by this building permit application. .
X (�iO4 n P-)UL(Ak`I 5
Print Owner's Naine(Electronic Signature) 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
contained in,this application is true and accurate to the best of my knowledge and understanding.
USE Sg1 N—,-L's -1 1-3
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
r 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
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"
_ 1