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10 DUNDEE ST - BUILDING PERMIT APP JACKET KIDE The Commonwealth of Nlassachusetts CITY OF Board of Building Regulations and Standards 13 �F Massachusetts State Building Code, 780 CNIR �✓� ewsed:filar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Da .Applied:' Building Offi.1(Print Name) SignatureDate SECTION 1:SITE INFORNIATION L1 Poperty Address: 1.2 Assessors blap&Parcel Numbers ISD DL)N D E F--D S'T" 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 'Zoning Information: IA Property Dimensions: Zoning District Proposed Use Lot Area(sq It) Frontage(Il) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required ProviJed Required Provided Required Provided 1.6 Nater 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 13Public 13 Private❑ al Check if es❑ p Po y SECTION 2: PROPERTYOWNERSHIPI' 2.1 Owner'of Record: ��9 PJ UL ADA9 yl o SA r6 NN)rne(Print) City,State,ZIP /0 Du^lo .A Sr 9V 7 z9-!J.9 No. and Street Telephone Email AJJnsS SECTION 3: DESCRIPTION OF PROPOSED\YORK°(check all that apply) New Construction❑ Existing Building Z- Owner-Occupied 61 Repairs(s) Alterations) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify: Brief Description of Proposed Work-: C Y S/Y SECTION 4: ESTLNIATED CONSTRUCTION COSTS Item Estimated Costs: OMNI Use Only Labor and Materials) I, Building S I, Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical 5 ❑Total Project Cost'(ftem 6)x multiplier x 7. Plumbing S P Other Fees: $ it. Nlechviical (HVAC) $ List: 5. Mechanical (Fire $ Total All Fees:S Su ressimt) qg Check No. CheckAmowi[: Cash Amount: 6. Total Project Cost: S ZJ, /�� ❑Paid in Full ❑Outstmldiug Balance Due: 5 NAEIZ 5-tF:M-- ►°t z3 ca � � T1� - 3-►s -I �sa I, -r• SECTION 5: CONSTRUCTION SERVICES 5.1 Cpnstruction,Supervisor License(CSL) D �-� r r• yiFr uSTi/✓e7 "!s L� License Number E.epirutiun Dale Nanle of CSL Holdef List CSL'fyp (see see below) Type -- '. - Description No.a Street s d �7 U Unrestricted Uuildin s tip-to 35,000 cu. It.) AB�I�✓J /� ��/ 6 R Restricted I&2 Runil Dwellin C i ylfown,State,W i\t Masonry RC Rooting Covering WS Window and Siding SF Solid Fuel Uuming Appliances /'v�// �lf,Sri/✓�/17��D�/r,(yyil,0 1 Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) t �oNc.�,LUGT'r V N HIC Registration/LLG J cJ , egistration Number Expiration Date f IIC Company Ni�nne ur HIC Registrant Nam rL G at rZ D �i� U iNorrec�4/7SN No. and StreetEmail address R-5,?I0Sl// Ci !Town State ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.g 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 Isluance of the building permit. Signed Affidavit Attached? Yes ..........❑ No........... O 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 t9 act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Dale SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of tate information contained In pplication is true and accurate to the best of my knowledge and understanding. Print liter's or Authoriz Agents Name(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%I.G.L.c. 142A.Other important information on the HIC Program can be found at w+vw.mass..,my oca Information on the Construction Supervisor License can be found at w++w.mass.eov'dps 2. When substantial work is planned,provide the information below: 'rota[ 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 .i. "Tolal Project Square Foolagp'may be,nbstituted I'or"Total Project Cost" ' , . ��- - ; .; � 11� - �y -- lq� c� R� z3 �; z� �' , �, The Commonwealth of Massachusetts " �{�y GES � Boazd of Building Regulations and Standards tNS ECTt�{Q�o� Massachusetts State Building Code,780 CMR SALEM � a r�sl 13 -'g�' O Building Permit Application To Construct,Reparr, Renovate Or Demolish a10 4� , One-or Two-Family Dwelling � This Sectiou For Offic' Use Only � Building Permit Number: Date ppplied: `� � 1 I ✓J�v�.� �6 l � Building Official(Print Name) . f Signazure . . - . . �� . SECTION 1:STTE IPiF'ORMATION �' 1.1 Pro e Address• P / _ �f� 1.2 Assessors Map&Parcel Numbers ///���� /p �n�T � I.I a Is this an accepted street?yes no Map Number Pazcel Number 1.3 Zoning Informalion: � 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 I Required Provided i Required Provided Required Provided � 1.6 Water Snpply:(M.G.L c.4Q§54) 1.7I Flood Zone Information: 1.8 Sewage Disposal System: Public❑ private❑ Zone: _ Outside Flood Zone? � Check if es0 M�cipa(O On site disposal system ❑ SECTION 2: PROPERTY 0R'NERSHIP� 2.1 q�ver o Recor� I �rv�ti /�a li.� ffG�ar r U I �Gf�-C{�-i /� /J Name(Print) ` Ciry,State,ZIP /t�.�r.t n�e� ��� I 7�9,� 700� No.and Street � Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply) New Construc[ion❑ Exisfing Building O4 Owner-0ccupied ❑ Repairs(s) ❑ Altera[ion(s) O Addition ❑ Demolition ❑ Accessory Bldg.� f Number of Uniu Other Specify: �f'1,,,,{o,�ar.�,J Brief Description of Prop e�l Worl�: � - �dq��� r� , G � o r SECTION 4�ESTIMATED CONSTRUCTION COSTS Item Estimated Co'sts: OtLcial Use Onl Labor and Mat�rials y 1.Building $ � 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ I ❑Standard City/fown Application Fee O Total Project Cost3(Item6)x multip(ier x 3.Plumbing $ � 2. Other Fees: $ 4.Mechanical (HVAC) $ I List: 5.Mechanical (Fire Su ression $ I Total All Fees:$ Check No. Check Amount Cash Amount 6.Total Project Cost: $ 3� „ - ❑pa�d in Full ❑Outstanding Balance Due: SEh1T � Z� �G � I SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License (CSL) 'A -71-7 —7 y A 3 fP License Number Expiration Date List CSL Type (see below) Name of CSL Holder Eric W. i :dill No. and Street 3 1likonType Salem MA O'197O Description - - - U Unrestricted (Buildings 2p to 35,000 cu. ft. R Restricted l&2 Family Dwelling City/Town, State, ZIP M Masor RC Roofing Covering WS Window and Siding O 1 SF Solid Fuel Burning Appliances I 1Insulation Tele hone Email'addmss D I Demolition 5.2 Registered Home Improvement Contractor (IHC) / tiara i� Wetathe[iZ>�finry t T r U HIC Company Name or HICRrgi� AvenueNo. j L12v�Cj RIC Registration Number Expiration Date and Street Salem MA 01970 Ci /Town, State, ZIP ---Telephone Email address SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6)) Workers Compensation Insurance affidavit this affidavit will result in the denial of the must be completed and submitted with this application. Failure to provide Issuance of the building permit. Signed Affidavit Attached? Yes ........IF. No ........... ❑ SECTION 7a: OWNER OWNER'S AGENT OR AUTHORIZATION TO BE COMPLETED WHEN CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner of the subject property, hereby to act on my behalf, in all matters relative to ham- a.&-c Q i uthorize 45-:c C4 IM work authorized by this building permit application. ZL14 414,r I Date Print Owner's Name (Electronic Signature) SECTION 7b: OWN *WOR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest4under contained inks applica t(on is true accttrate the pains and penalties of pedury that all of the information to the best of my knowledge and understanding. Signature) Date Print Owner's or Authorized Agent's Name (Electronic NOTES: I. An Owner who obtains a building permit (not registered in the Home Improvement program or guaranty fund under M.G.L1 www.mass.eov/oca Information on the to do his/her own work, or an owner who hires an unregistered contractor Contractor (HIC) Program), will not have access to the arbitration c. 142A. Other important information on the HIC Program can be found at Construction Supervisor License can be found at www.mass.eov/dps 2. When substantial work is planned, provide Total floor area (sq. ft.) Gross living area (sq. ft.) Number of fireplaces Number of bathrooms Type of heating system Type of cooling system 3. "Total Project Square Footage" maybe the information below: ( (including garage, finished basementlattics, decks or porch) i Habitable room count Number of bedrooms Number of half/baths Number of decks/ porches Enclosed Open substituted for "Total Project Cost' CIL z6q s� The Commonwealth of Massachusetts RECk I = CITY OF BoazdofBuilding Regulations and Standazds IP(SpFCfl0� �D S P Massachusetts State Building Code, 780 CMR QE.', �� 2011 r � Building Permit Application To Construct, Repair,Renovate Orngtto ph Revised Arpr I P One-or Two-Family Dwelling CC 2. 00 l�' 1 Irk This Section For Official Use Only.. v/ Building Permit Number: - Date Applied: iU 4t�� -'� 9I �t Building Official(Print Name) , . 4 Signature _. _ Date SECTION 1:SITE INFORMATION 1.1 ProperVddress• 1 1.2 Assessors Map&Parcel Numbers 1.1a 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 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 O�yper 1Reco dI �� / ,,, Yaw Adar�a K 014 Name(Print)int) City,State,ZIP /r No.and Street '�Telephone Email Address - SECTION 3:DESCRIPTION OF PROPOSED WORK''(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 A teration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other pecify: Brief Description of Proposed Work2: SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ 7176v . .i 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ - Su ression Total All Fees:$ Check No.0161 Check Amount: Cash Amount: 6.Total Project Cost: $ -7� ❑Paid in Full ❑Outstanding Balance Due: 1n(3til.ZO tlu SiaSar qlz $ i SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) pi-?C.7 Z3 / License Nl/umber Expiration Date Name of CSL Holder /L List CSL Type(see below) L( Eric W Pttlm Type Description No.and Street3 Hilton Street U Unrestricted(Buildings up to 35,000 cu.ft. Salr�II�1,4tl-914'r"� R Restricted 1&2 FamilyDwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding ITSF Solid Fuel Burning Appliances ` a / "I ✓ [ Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) Atlantic Weatherization LLC HIC Registration Number Expiration Date HIC CompaiglN ,ff eA arae No.and Street AA_$Iehll. Email address Cit /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 .......... 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 t C 1 K /411 to act on my behalf,in all matters relative to work authorized by this building permit application. �3 Cy, Ito) 9� 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 I'catioryls[rue and accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) Date 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.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dus 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"