12 ENGLISH ST - BUILDING PERMIT APP The Commonwealth of Massachusetts
k; Board of Building Regulations and Standards CITY OF
4^ Massachusetts State Buildin Code, 780 CMR SALEM
'':« g Revised Mm•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: to Applied:
Building Official(Print Name) VSigna Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
I Z Eno�i,s h .Si
1.1 a Is this an accepted street. yes no M aPNumber Parcel Number
1.3 Zoning Information: - 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(it)
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 ifyes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
Ledwn r.) I7rr It/e /;Z. InA 01970
Name(Print) City,State,ZIP
/Z Ena�,c 97�3 -.37io - os7
No.ando.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check atl that apply)
New Construction❑ Existing Building I Owner-Occupied ❑ Repairs(s) Id I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other ❑ Specity:
Brief Description of Proposed Work Z: e
1 r -�-
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (IIVAC) $ List
5.Mechanical (Fire $
Suppression) Total All Fees: S
00 Check N t i Check Amount: Cash Amount:
6.Total Project Cost: $ 500 . 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
_ 9S53y �
ba J I ' P,a n$o r) License Number Expirauon Date
Name of CSL Holder
List CSL Type(see below)
R Ff-a n Ave-
No.and Street
Type Description
I U Unrestricted(Buildings up to 35,000 cu. ft.
W H G3 8Co 5 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
y7f3_ S3& _ 1-1yci I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
1fc-15Cn7
Tan n r L HIC Registration Number xprratron Date
MC Company Name or BIC Registrant Name
,93 y lqn t Inn k,4
No.and Sueet Email address
0 97a-A3G -/'7Y9
Ci /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 .......... a No ........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I I,as Owner of the subject property,hereby authorize bayl iF_/-C-
to act on my behalf,in all matters relative to work authorized by this building pe t application.
)� F Ll /Qt Z /,//o1/,z
Print Owner's N e(Electro 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 this application is true and accurate to the best of my knowledge and understanding.
a/i,/ . /Wari"4'IZ N/iu /ice
Print Owner's or Authorized Agent's 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 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.nrass."ov/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'