19 EDEN ST - BUILDING PERMIT APP (o
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
ne_,or Two-Family Dwelling
'Phis Section For Official Use Only
_ Building Permit Number: Date Appli :
'O BuildiagOJliciat(PrunName) Signaanc
SECTION 1:SITE INFORMATION
1.1 Perly Adrropdress:�/ 1.2 Assessors Map&Parcel Numbers
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1 I Ph SIB
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L la is this an accepted street?yes no Map Number Parcel Number u, "o
(1 1.3 Zoning Information: 1.4 Property Dimensions: i
tlJ Q
Zoning District Proposed Use . Lot Area(sq ft) Frontage{it) O" >
1.5 Building Setbacks(ft) N
Front Yard Side Yards Rear Yard ,� _z
Required Provided Required Provided Required Prouded F;
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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?Check ifyes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Print) City,State,ZIP
/ 9 St—
➢ rz 9fs?�
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED W ORIV(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other Ck'<pecify:
Brief Description of Proposed
tW�ork2:/1 r t d
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SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical - — $ 0Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. echanical (Fire $
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ S 0, p ❑Paid in Full 0 Outstanding Balance Due
Iu C(IA.t" (o l 1
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SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
10 6Q&11 a�?
License Number Expiration Date
.: CSLEoZor
List CSL Type(see below)
2 '1'ypc Description
No. and Street
U Unrestricted(Buildings up to 35,000 cu.ft.)
+�tiY�t/P-✓s ✓ //��! 2- R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
�r rt t. A&San y a A o r.Q HIC Registration Number Expiration Dab
HICpp 1;
Cnompppazry Nam6�e-c .�HIC Registr tt Name
tQ eur
No. and Street Email address
. Cn /am /17 14
City/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 Tssuance.9f the building permit.
Signed Affidavit Attached? Yes.......... No...........U
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
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: 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 application is true and accurate to the best of my knowledge and understanding.
Print Owners 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 MG.L.c. 142A Other important information on the HIC Program can be found at
www.massgov/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"