36 DERBY ST - BUILDING JACKET dAyes
ga The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dw tng
This Section For O cial Use Only
Building Permit Number: I DAe Applied:
Building Official(Print Name) Signature
SECTION 1:SITE INFORMA
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
a
I.la Is this an accepted st eet?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq flu Frontage(fl)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owry�'of Record:
j Fk &AY T-k V edL MA 01 S 2�
Name(Print) City,State,ZIP
Cr✓L24�J1e.a F Dez 1)A- SOO- 951?
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑�Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other 2-5 city: fA/w13Th.6�l Z5%r
Brief Description of Proposed Work': ci W
SECTION 4: ESTIMATED CONSTRUCTION COSTS-
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 3 oo 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
L. Plumbing $ Other Fees: $
4
. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Su ression Total All Fees: $
6.Total Project Cost: D Check No. Check Amount: Cash Amount:
$ '�/(-f ❑ paid in Full 0 Outstanding Balance Due:
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
.' /y1 OTC /0347 1-43-ate
�ty License Number Expiration Date
Name of CSL Hold
List CSL Type(see below) F'J
No.and Street Type Description
nC (� q U Unrestricted(Buildings u to 35,000 cu.ft.
VaAr CS N"i U��Z R Restricted 1&2 Family Dwelling
City/Town,State,7.W M Masonry
RC Roofing Covering
WS Window and Siding
��/�� SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 RRc tstered Home Improvement Contractor(HIC) I6yS�6g �O-Zf-ZOO
J6 M&J07e HIC Registratioonn Number Expiration Date
HIC Comparly Name or HIU Registrant Name
No and Street Email address
—m`Now_
City/Town, Sta[ 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 f 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 C rr"V 5 M V/\,
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 76:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 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 Authori ed Agent's Maine(Electronic Signature) Date
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 can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
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"