27 DEARBORN ST - BUILDING PERMIT APP The Commonwealth of Massachusetts FOR
Board of Building Regulations and Standards MUNICIPALITY
Massachusetts State Building Code, 780 CMR T� edition "0 Mr USE
Building Permit Application To Construct,Repair,Renovate Or Demolliitsh a i" Revised January
(f� One or Two-Famili; e inn
OV This Section Fo Me I Use 0,
BuildingpermitNumber: Date pplie .
Signature: Daze
Building Commissioner/]nspe or of Build gs
SECTION 1: E INFORMATION
1.1 Property Address: 1.2 Assessors Map S Parcel Numbers
sl_
a �
1.1 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 ft) Frontage(ft)
1.5 Building Setbacks (ft)
Front Yard
Provided q
Side Yards Rear Yard
Required
Re uired 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❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow/ner'1of Record: �L—
tl0.'F�12 .
Name(Print) p Address for Service:
oo cjI .7
Signature TelephoDe
SECTION 3:DESCRIPTION OF PROPOSED WORK(cbeck all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
z 5 e
Brief De of SProposedl,V✓orkZ: CC,
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials
I. Building Permit Fee: $ Indicate how fee is determined:
I.Building $
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Suppression) Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 9 0 .Ob ❑Paid in Full ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.7 Licensed Construction Supervisor(CSL) ,
73 /
License Number Expiration Date
Name of CSL-Holder - r
3 IT11 L,�'jrPel 1f List CSL Type(see below)
Address .Sa�Cm Tt t1197n IM
Descri Lion
icted(u to 35.000 Cu.Ft)
Signature ted 18a2 Fami]} Da-etline
,OnlyTelephone ntial Rooting Coverinntial Window and Sidingntial Solid Fuel Bun n°A liance]nstallauoutial Demolition
5.2 Registered Home Improvement Contractor(HIC)
/Y1o ��
P > eg an ame Registration Number
H1C Com an- 610 kffirsW AYOW
Address Salem MA 01970
Signature 17�f 7yt/—$/y/ — Exprati�Dart
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 Issuanc f the building permit.
Signed Affidavit Attached? Yes ..........er No ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
U I n 5 , as Owner of the subject property hereby
authorize t, c_ ru,( to act on my behalf,in all matters
relative to work authorized by this building permit application.
7behalf-
PmntN=e Date
'SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
,as Owner or Authorized Agent hereby declare
and information on the foregoing application are true and accurate,to the best of my knowledge and
/J
Signature of Owner or Authonzed%{gent Date
(Signed under the pains and enalties of euw)
NOTES:
]. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(riot registered in the Home]mprovem ent 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 1 I O.R6 and I I O.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 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"