4 CYPRESS ST - BUILDING PERMT APP Z
- - - - /-Ae� 13gab 25
:a I'Ite Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
tY i, Massachusetts State Building Code, 780 CNIR SALEMI
'L'-,•• Krrised.l l,u•'ill/
Building Permit Application To Construct, Repair. Renovate Or Demolish a
One-or rwo-Fumilr Du elliu,Sr
This Section For Official Use Only
Building Permit Number: Date Applied: 1 1 —1 q — 1-5 _
lhilJing Olticial(Print Name)
Uata
SECTION I:SITE INFORMATION
1.1 ro rty Address: 1.2 Assessor hlap g Parcel Numbers
I.la Is this,n accepted street?yes L n Mhip Numimr Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District fln posed tJse Lot Area(sq It) Frontage I It)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.§Sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private O Zone: — Outside Flood"Zone? Munici al O On site disposal )
Chock-I-cs0 P Wsal s stcm ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owne{{t of R cor
fn7�ln�e IPa/ S
N;mte(Pn Q
r y��r.pp City.State,ZIP
Nu.anJrcy �'7��3
St
Telephone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demulition ❑ Accessory Bldg.❑ Number of Units Z Other X Specify:
Brief Description of Proposed Work-:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
I Labor and Materials) Official Use Only
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard City?uwn Application Fee
❑Total Project Cost'(Item 6)a mPulti her _ _ x
7. Plumbing S — - ----
_. Other Fees: S
J. .\tech;mical ill\'.1('1 S List:
5 .Vcchanicul (Fire -- --_--- ------- - -- -- -
Su,nessionl S Total .\II Fees: S-----
I,
�LQ b Check \'o. _('heck Amount: l',uh \mount:
Total Project Cosh. S d+Z�/ ❑Puid in Full ❑Oulst;mdin Balanc
e:mee Doc:
M A t( TU G¢)Q7-p-fa C.TorZ
SECTIONS: CONS 7'RUC'noNSFRVI('F.S
5.1 (`onstruction Supervisor License(CSt.)
IL 1'/Y✓Lfo lam!'-` _ _.---- I.ieenw Nunhcr
Nmnco(CSI. IIIlolder.\ I p ist0l. I\ clsarhdowl_ _
V-3 6(%�(!�Y_r"_'—_ ..--._. .___—____-_— rh)pc Description
Sl No. and rcal
-76 11 Restricted
1 I2 Family
ami i 1$,n110 cu. Il.l
R Restricted 1 l2 Pami1� Dwcllin
OtNifoon.State./IF M Nlasonry
RC Roolin Covcrinii
IN Window;md Siding
SF Solid Fuel ihrning,\pplianees
Q �l/�`3y,/ /l/J,g�3 bUoc Cp ya ep1T { Insulation
l'ck bona Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) //9G77
IIIC'Iicg6Iruiun Numlwr lisps alien Date
I IIC C'oll0it) Name I IIC Rs it Nunlc AIXJ lj p\ � a A C 4jTT-P'C7—
N t Sure M oto (6 Emus)addrcsn
City/Town. State,ZIP Talc hone
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 ......... No........... ❑
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize fl I c ap"`� Klj `
t�9� =7777:
t n m b indb his building permit application.
�l /'e ):3
Print mers Nwne(Electronic Signature) 0fe
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
contained in this application is true and accurate to the best of my knowledge and understanding.
Prim Oencr's ar:\uthorircJ,\gcnt's Nunw 1 hlectruns.Signature) ate
NOTES:
1. An Osnner whu obtains a building permit to do his•her own work,or an owner who hires an unregistered cuntractur
(not registered in the Home Inlprovenlent Contractor(HICI Program),will na have access to the arbitration
program or guaranty fund under I.G.L.c. 1 4_2A.Other important information on the HIC Program can be found at
loN n .r.. �;,,% o, i Information on the Construction Supervisor License can be found at $p% 111,
2. \\'lien substantial lurk is planned, provide the information below:
7otai flour area Isq. R.) - _,___--_I including garage, finished basement attics.decks or porch)
Gross living area uy. Ilan ..---- _-- _—.
Habitable room count
Number of fireplaces_._ _ Number of bedrooms
V unahcr oFhathnwmi . . _ _ . Number ofhalf•ha(hs .. - .
I)lie of heating s)item .. . _ Number of decks, porches -
f)pc of cl+oling S)ilcnl Unclosed tlpcn _
1. "l oral Project Square Foolage"I'M he substitute) lirt"I'al;d i'rnject C'wi'