4 ENGLISH STREET - BUILDING PERMIT APP 1 t
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
� r Massachusetts Slate Building Code, 780 C'MR, 7,a OF SALEM edition RevixeJJumurrr•
Building Permit Application To Construct, Repair, Renovate Or Demolish a I. :rHAY
One-or Twu-Family Dwelling
This Lion For Official Use Only
�-' Building Permit Number: Date Apply : Q ! a
Signature: OZZ r)/,
Huildin am t N n ar 48, izap�—rate
ECTION 1:SITE INFORMATION
1.1 Prope Add 1.2 Assessors Map& Parcel Numbers
I.I a Is Chia an acee red 1?yes no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Area(sq 11) Frontage ill)
I.S Bulldlall SeIDacW(R)
From Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I,c.Jo,§Sa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public O Private O Zone' _ Outside Flood Zone? Municipal O On site disposal system O
Cheek if es0
SECTION2: PROPERTY OWNERSHIP'
2.1 err,of Reco
Name(Print) �— � � Address fa/r Service:
Signature Telephone
SECTION J: DESCRIPTION OR PROPOSED WORKS(check all that apply)
New Construction O Existing Building O Owner-Occupied O Repairs(s) O Alteration(s) O Addition O
Demolition O 1 Accessory Bldg. O Number ofUnita_ Other O Specify:
Bri f Description of Proposo Work': fL
W
SECTION d: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Omclal Uae Only
Labor and Materials
1. Building S 1. Building Permit Fee:S Indicate how fee is determined:
�. Electrical S O Standard City/Town Application Fee
O Total Project Cosa'(Item 6)x multiplier x
). Plumbing S 1. Other Fen: S
1. Mechanical (IIVAC) S List:
S. Mechanical (Fire S
Su ression Total All Fees:S
Check No. _Check Amount: Cash Amount:
6. Total Project Coat: 5 Paid in Full 13 Outstanding Balance Due:
SECTION S: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) MN�bcr
Natao'L'SI.•11 I er ow)
Description
:WJrcss U Ilnrestrictcd u to 33,000 Cu.Ft.)
R Restricted I32 Famil Dwelling
Signature M M Only
Residential Roulin Covering
(e ephrxte Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Inslallaliun
D Residential Demolition
5.2 �te�re House In/p=vereent Contractor(HIC) �G O
I IIC pant N ur lit egistrant Registrati n Numbe
� a e �B�
AJJr}D�/ d !�- 9Tfl $';p �G�— expiration'Date
jai ufdt Telephone
anal
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,e. IS2,f 25C(6))
Workers Compensation Insurance atfdavit 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...........O
SECTION 7a:OWNER AUTHORIZAT ON 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.
sisuissure ofowner Date
S CTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
( ,as Owner or Authorized Agent hereby declare
tha fa6iiition on the foregoing application arc true and accurate,to the best of my knowledge and
behalf.
Print Name
Signalure of(honer or Authorized Agent Dale
(Situted under the osins and penalties of 'u
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 gg have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I IO.R6 and I IO.RS,respectively.
When substanlial work is planned,provide the information below:
Total tloors area(Sq. Ft.) (including garage,finished basement/at ics,decks or porch)
Gross living sea(Sq.Ft.) Ilabitable room count
Number of fireplaces Number of bedrooms
Lumber of bathrooms Number of half/baths
ype of heating system Number of decks/porches
ype of cooling system Enclosed Open
"Total Project Square Footage"may be substituted for"Total Project Cost"