22 DEARBORN ST - BUILDING PERMIT APP (002) 'i
c.K. 39s 3 *q
The Commonwealth of Massachusetts JRECEIVEDITY OF
Board of Building Regulations and Standati�sSPEALEM
Massachusetts State Building Code, 780 CMRsed Mar 2011
Building Permit Application To Construct,Repair, Renovat16l`5r9
MOne-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
L n, Building Official(Print Name) _'Signature Date
SECTION 1: SITE INFORMATION
l 1.1 Pro a Address:7 Op rty C � 30k 1.2 Assessors Map&Parcel Numbers
1.la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
lzi� I V el\m A41
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:
Zone. _ Outside Floo Zone?
Public Private❑ Check if yes - Municipal, On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2. Owner'of Record:
Lj-/,s fYl Lc�J �`A O Pe_e-WAtDb �z—
Name(Print) City,State,ZIP
r8 zat��n� I>rz, V r= r7�t 7aL/- 787v
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction Existing BuildingK Owner-Occupied Repairs(s) ❑ 1 Alteration(s) JK Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other, ❑ Specify:
Brief Description of ProposedWork2: I_z_6V
L - co
n OGV_ 1 V 2
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Labor and Materials) Official Use Only ,
1. Building $ O _ 1 Building Permit Fee $ Indicate how fee is determined-"
❑ Standard City/Town Application Fee
2. Electrical $ �, s „ €
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing $ , 2. Other Fees ,$ =,
4.Mechanical (HVAC) $ List:
M
5.Mechanical (Fire $ $Total All Fees.
Suppression)
Check No Check Amount Cash Amount ,t '
6. Total Project Cost: $ eo0 ❑Paid inFull ❑ Outstanding Balance Due."
zo 65;�Pvii2 r_
"k
SECTION.5: CONSTRUCTION.SERVICES
5.1 Construction
tion Supervisor License(CSL)
H'/C�"Y[7 O9 / /�
, ����/�/�,�'j(f�� License Number-� Expiration Date
Name of CSL Holder ,
List CSL Type(see below) -
o 'DRIYE
No.and Street Type Description
01960
/ a 6� Unrestricted(Buildings u e cu.R.)
,T / R Restricted 1&2 Family Dwelling
City/Town,State,ZIP - M Masonry
RC Roofing Coverin
WS Window and Siding
y SF Solid Fuel Burning Appliances
/ I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) Q �a. (-7
HIC Registration Nurriber pirate Date
HIC Company Name or MC R�istrant Name _
„Z(9 � GP(/UeL - Wit° I VZ
"D, y &14 01 t o ����� Email address
Ct /Town, State, 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
I, as Owner of the subject property,hereby authorize
to act on my behalf, in all matters relative to 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
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electron gnature) te
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.eov/dris
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"
4 .
Professional Land Surveyors,& Civil:Engineers:
ESSEX SURVEY SERVICE: 1958 - 1986
OSBORN PALMER 1911 - 1970
BRADFORD & WEED 1885 - 1972
PLOT PLAN OF LAND
LOCATED IN.
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I hereby,cert'fy to rl�t si9LE7�
KZ AA! -:1W IZZT I that the::
buildings are located on the
ground as shown.
SCALE: / :Za ^pn
DATE: JUL Y 2 2U
- 1 R. R
REFERENCE: BK 3jlJ(o PG' 73 Christopher R Meld PL Lgg317
;QNo.31317 O
El
104 LOWELL STREET
PEABODY, MASS. 01960
(978) 531-8121
.:FAX- (978)'S31`--5920
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