3 DEARBORN ST - BUILDING PERMIT APP the Commonwealth of Massachusetts
�. Board of Building Regulations and Standards CITY
!�
Massachusetts State Building Code, 780 CMRm OFSALEM
, 7 edition
� 1 : Revised Juwau•v
Building Permit Application To Construct, Repair, Re ovate Or Demolish a 1. =008
qr/u One-or Ttv -Fc nily Dwellin
This 56ction F r Official se Only
Building Permit Numbe /y'. Date plied:
Signature: L qz
Building Commissioner/1 pectorofl ui gs Date
SECTIO . SITE INFORMATION
t '/ 1.1 Property Address: V 1.2 Assessors Map& Parcel Numbers
l/ -3 Je A W S1
I.I a 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 fi) Frontage(11)
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:
Zone: _ Outside Flood Zone. Municipal ❑ On site disposal system
❑
Public❑ Private❑ Check if yes[] p p y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
Jdre� yyl 0 A4 011
Na m -1104 � Addre s�ry ce:
1ure Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
B2Z'Descrlliption of Proposed Work'-: a �c s e Ice etv vvt Gr'f—
�- Ii I N` u< O r- S P v ca,r
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $ _�Y{,�
4. Mechanical (HVAC) $ List: (�
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No._Check Amount: Cash Amount:
6.Total Project Cost: S /, $ 9-0 ❑Paid in Full ❑Outstanding Balance Due:
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
7�nti l . t P 7 ft T G c> License Number Expiration Date
Name of CSL I[o]der
List C'SI.Type(see below)
rype Description
Addre
�� U Unrestricted(up to 35,000 Cu. FL
I2 Restricted 1&2 Family Dwelling
Signau M Mason Only
RC Residential Roofing Covering
Td• one WS Residential Window and Siding
G,, G 2 G y _ G y ` 7 SF Residential Solid Fuel Burning Appliance Installation
O D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature 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 .......... ❑ 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 'i
relative to work authorized by this building permit application.
ature of Own Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
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 of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
NOTES:
I. 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 I 10.116 and I IO.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 halt7baths
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"