9 DAY AVE - BUILDING PERMIT APP 4% , 67
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
\ Massachusetts State Building Code,780 CMR SALEM
ppp Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
` This Section For Official Use Only
1 Building Permit Number: I Date A lied:
410a
Building Official(Print Name) Sig," Date
SECTION 1:SITE INFO ON
1.1 Pro a Address: 1.2 Assessors Map&Parcel Numbers
W� me.
L la Is this an accepted street?yes ✓ no Map Number Parcel Number
13 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 Pmvided 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 OWNERSHIP'
2.1 Owner'of Record:
c h QVICaInr� c5C>Qam . MR 01G`1D
Name(Print) City,State,ZIP
OI Aq C1UQ filX•`14;5 •20q-1
No.and Street V Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building N1 Owner-Occupied Ed Repairs(s) ❑ 1 Alteration(s) la I Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work : LLA will M s} �lcvr4Jb areA i n-%+a D-
sh6t,AT Sfi�hG �vtlt
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:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ q-qCL)-tz 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ /,/G ac4r -❑-Pfaaiid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
CS- 6733'15 6q 1(1312o 1-+
CIGr� r. II IIiY phV License Number Expiration Date
Name of CSL Holder
Lis[CSL Type(see below)
11 kArNmare J)r.
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 co.ft.
Tanvers. MA, R Restricted 1&2 Family Dwelling
City/town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
/� -f 1 SF Solid Fuel Burning Appliances
31-14 brlan @ larowhs kh .[nrV% I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 1031011 �1IG Zol4
-BC6t xl S kJLllv� a Cen\er HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
-12 briar\ LO browvSkh. CDrr
No.and Street Email address
1�ir�uers . MA �IG2� 9lX-'11431"14-
Ci /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 .......... III( No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize '�ty}'Lq i � `Xp t ge-A'In '
to act on my behalf,in all matters relative to work authorized by this building permit application.
„ (o vo r3
Print Orffr's Name(E nic Signature) Date
S CTION 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 app ication is true and accurate to the best of my knowledge and understanding.
LL . to
Print O 's or Authoi gents Name(Electronic Signature) Date
NOTES:
l. 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/dos
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"maybe substituted for"Total Project Cost"