4 DUNLAP ST - BUILDING JACKET [ y
The C'onumonw'e:dth of Massachusetts
Board Of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 730 C'MR SALEM
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-ur Two-Family Du rHii X
This Section For Official Use Onl
Building Permit Number Date applied: '
Building 0111cial(Print N;ane) Signaturelo Date
SECTION I:SITE INFORMATION
/ 1.1 Property AtNre��GD s.L_e 1.2 Assessors Map& Parcel Numbers
!/ I.la Is this an accepted street?yes J/(no Map Numher Parcel Nuinber
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Fr,posed Use Lot Area(sy (t) Frontage(R)
1.3 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.§54) 1.7 Flood Zone Information: I.g Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if yesO Municipal❑ on site disposal system (3
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Re r A /
Name(Prm Uq.State.ZIP
l S� �
Igoe S e k `%�— `,
No.and Street D
Telephone hmail Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Denwlition ❑ 1Accessory Bidg. ❑ I Number of Units_ Other ❑ Spcci l'y:
Brief Description of Proposed Work=:
SECTION a: ESTINIATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and .Materials) Offlcial Use Only
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
'. Electrical S ❑Standard City/Town Application Fee
j ?. Plumbing S ❑Total Project Cost(Item 6)x multiplier x
_'. Other Fees: S S� \
1. Mechanical (II\':\('1 S List:----- --- _ /�.
S. Mechanical tFirc
.Su,ttcssion) S 'total :\IlFees: S.--_---------- ..._._..--- -
✓ e. Total Project Cost: Y ('heck No. ---('heck :\nunuu: _ --_-Cash :4uounc _ -
❑Paid in Full 0 Outstanding Balance Due:
rowV „c
1 +
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Su iervisor License(C'SL) 111212 Pla
—__ /./. . - Liemue Nunther Pgtirwion D;ue
N:une of l'SI. (Folder
J List C'S1, I)pe Iscc helotvl
_��.-14�-- JI�Q --- ------�----- 'I\pu Description
No. and Street
II (Inrc>lricicd I Ihlildings up m 35,0110 cu. It
SQ 'e- (N1 / �( _ v I Q �... - R Reitrictcd I r? Tamil Y MWIhn
01vi foml,State.LIP NI Nfawllry
RC Rimlinit Cmerin
WS Window and Siding
SF Slid fuel Miming Appliances
_ _- .20 I
Entail addressMInsulafion
Demolition
5.2 Registered Flom Improvement Contractor(HIC) �Registration Number Ifspirnl' m Date
I IIC'C' opunyy,,Name or I IIC' R-fl; nt Name //
Uu h j�0 Gw e G M Amt C rU �t aT6z +� a`S
No. midi"'5, /n„4. 0 f Q�a (:mail address
Cit /Town.State,ZIP r"` lrele hnne
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 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: OWNEW 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 lie ion is tru cc ate to the best of my knowledge and understanding.
Print Ott nt. . nr:\mhorireJ.\gent's N;une I I.Icetronic Signalurel Data
(III No rEs
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 Hume Improvement Contractor(HIC) Program).will rro have access to the arbitration
program or guaranty fund under M.G.L.c. la_'A.Other important information on the HIC Program can be found at
\hoot n,.n, p,t ,,) t Information on the Construction Supervisor License can be found at tt tot na,:Llos .Ip.
2. \%'lien substantial work is planned, provide the information below:
Total floor area(sq. a.) _ (including garage. finished bascment'attics.decks or porch)
Gross living area Isy. 11.1 _ Habitable room count
Ntnuber of fireplaces_-- Number of bedrooms
Ntunher of bathrooms -_ .Number of half baths
I)pe of heating Sy stem Number of decks, porches
1\pc of an+ling syitent .. ._ . -_ -.- Enclosed . . . Open
I
I
i. ''fatal Project Square Foolage" ma) he substituted fir"Total Project Cost-