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MML PEfi A TO; Z>vn IMP � G,/(f vrrc /JI 7 0 � q yN u { a gay-a� NMVDM OLJB� um NMI► VN 'L The Commonwealth of Massachusetts I Board of Building Regulations and Standards CITY OF ALEM OO M( Massachusetts State Building Code, 780 CMR Sd.thir 2evised.L(nr 20// Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Fa nily Dwelling This Section For Official Use Only Building Permit Number: Date AW Building Official(Print N;une). SignetDateSECTION l6 SITE INFORt�fALI Property Address: 1.2 Assessors p !�! s7- I.1 a Is this an accepted street?yes no blap Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq it) Frontage(It) 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: Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑ Public❑ Private❑ Check ifyes❑ p p y SECT[ONZ: PROPERTY OWNERSHIP'' 2.1 Owner'of Record: .( f rGc v /3-ll��l�.:an lc4ers✓n .Sra-/f �rn �—n� 0147cZ �y1me(Print) City,State,ZIP No.mt Stree Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied I Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ Number ofUnits_2_� I Other ❑ Specify: Brief Description of Proposed Work-, CJ/C t' SECTION 4: ESTIMATED CONSTRUCTION COSTS Item (Labor Costs: Official Use Only Labor and Materials) I. Building S I. Building Permit Fee:$ Indicate how fee is determined: $ ❑Sttndard City/Town Application Fee �. Electrical - - ❑Total Project Cost(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: .$ 4. �Icchvtird (HVr\C) S List: 5. Mechanical (Fire $ Suppression) "Cold All Fees:S 2 Check No._Check Amount: Cash Amount G. "fetal Project Cost: $ ✓ Lw,00 ❑ Paid in Full El Outstanding Balance Due: GAL_ � (-A>� ©✓K 1 j SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL holder List CSL'rype(sin below) No.and Street Type • Description. U Unrestricted (Buildings tip to 35,000 cu. 11.) R Restricted 1&2 Family Dwelling Citylruwn,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances [ Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) IIIC Registration Number Expiration Date IIIC Company Name or HIC Registrant Name No.and Street Email address City/Town,State,ZIP 'rele hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. IST.§ 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 t9 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 KBy 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(Electronic Signauve) 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. I42A.Other important information on the HIC Program can be found at www.massngav:'oca Information on the Construction Supervisor License can be found at www.mass.eov:/d tm 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. R.) 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",rot;d Project Cost" EIT�OFgxLEl� . PUBLIC PROPERTY DEPARTMENT u.awJkLfi, Nwraa 130 WASHU6=w Sr2M• sued 4wtiUCHMr1s ot97s APPLICATION FOR TIR REPAIR. RENOYATIoN_ cONSTRUCTION DEMOUM-N OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING STRUCTURE OR BUILDING. 1.0 SITE INFORMATION Location Name: <�, Building: Property Addrsar--- --- -- ---- --- -- Property Is located In a:Conservadon Area YM Historic Distrid YIN 2.0 OWNERSHIP INFORMATION 2J Owner of Land _ Name: Address: Telephone: 3.0 COMPLETE THIS SECTION FOR WORK IN E7IISIidt3 BUILDINGS ONLY Addition Existing Renovation Number of Stories Renovated Change in Use Nw Demolition Existing Approximate year of Area per floor (sf) Renovated construction or renovation of existing building New Brief Description of Proposed Work: NS� "rA51A GL ljr'� 51 i�, ,`Gt-40 Cv< L4 .23c<j —--------Mail Permit to: What is the Current Use of the Building? Material of Building? ifdwelW�g,how many units? Will the Building Conform to Law? Asbestos? ArchitsCf$Name Address and Phone Meehanles Name ST��Gi ✓Ll !�/� v Address and Phone C �� r� Construction guPervism license HIC Registration tl Estimated Cost of Project s Pemdt FeeCaleulation 6 Permit Fee i �a�` -�=� Estimated Cost X$71$1000 Residential Y Estirnated Cost X 5111$l000 Cammardat ------ -_.. - 00 An Additional $5.06 I's added as an f - Administrable charge. � 15 Make sure that all fields are properly and legibly written to avoid delays in Processing. The undersigned does hereby apply for a Building ermit build to the abov stated spec&ations. Signed under penalty of perjury ate i iJ �1 s s it 1 a The Commonwealth of Massachusetts Board of Building Regulations and Standards ' Town of ky p Massachusetts State Building Code, 780 CMR, 7"edition Building Dept Building Permit Application To Construct, Repair, Renovate Or Demolish a Ore-or Tiro-Family,Dwelling This Section For Official Use Only Building Permit Number: Date Applied: Signature: Building Commissioner/Inspect 'of Buildings Date SECTION 1:SITE INFORMATION I.I Pro ertY Address: 1.2 Assessors Map& Parcel Numbers D viv, S r 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 LQt Area{sq B) Frontage0system 1.5 Building Setbacks(ft) Front Yard Side Yards R 70private Provided Required Provided Required1.6 :(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage DispPo ❑ Zone: _ Outside Flood Zone? Municipal O On s Check if esCl SECTION 2: PROPERTY OWNERSHIP' 2.1 /, c7Af✓.—.G t1.,G��^�'s a., .-byA /....n .5f' Na ..(Print) Address for Service:—/ - Signature Telephone SECTION 3:DESCRIPTION OF PROPOSED WORK=(cheek all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) Cl Addition ❑ Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify: Brief Description of Proposed Workz: .S y'-C7 AC SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs; 011lcial Use Only Labor and Materials 1, Building S L Building Permit Fee: S Indicate how fee is determined: 2. Electrical 5 ❑Standard City/Town Application Fee ❑Total Project Cost((tem 6)x multiplier x 3. Plumbing $ 2. Other Fees: S 4. Mechanical (HVAC) S List: 5. Mechanical (Fire $ Su cession Total AtI Fees: $_ Check No. Check Amount: Cash Amount: 6.Total Project Cost: S 5/15` 0 Paid in Full 13 Outstanding Balance Due: 7 )567000 SECTION 5: CONSTRUCTION SERVICES L/ truction Supervisor(CSL) q- 3 License Number Expiration Date List CSL Type sec below) r 0�6�oD rP (see/I// T Descri tion M U Unrestricted(up to 35,000 Cu. Ft.) Signat R Restricted 1&2 FamilyDwelling ;- M Mason Only RC Residential Roofing Covering Telepbone 9� 7y0 / ,00 WS Res:demial Window and Siding 7 SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Reegg�istered Home Improvement Contractor(HIC) �'SC— voD R�AIaTiuG SF v/cBS / 3 Yaa o HIC Company Nme or HIRegistration Number )00 box ///I =E440 MA Address o�/a 97B ?yb /G 07 E piration Da e Signature Telephone 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 .......... 0 No........... 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, 15,c-,-,a ,/49AI zq&o gins Oi✓ m Owner of the subject property hereby authorize /24 7 1 otr 0S5 60x0 to act on my behalf,in all matters relative to work authorized by this building permit application. rbehalf. ner Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION as Owner or Authorized Agent hereby declare ents and information on the foregoing application are true and accurate,to the best of my knowledge and rntame Signature of Owner or Authorized Agent Date (Signed under the pains and penalties of perjury) 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 no/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 I IO.R6 and I I0.115,respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq. Ft.) (including garage, finished basement/auics,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"