32 ESSEX ST - BUILDING PERMIT APP arrvivirn
The Commonwealth of Massachusetts INSPEC IOMA FdSRVICE '
Board of Building Regulations and Standards MUNICIPALITY
Massachusetts State Building Code,780 CMR,7's edition �14.� N O UA LI S `
Building Permit Application To Construct,Repair,Renovate Or DemoSish.a ; ;Revised January
One-or Two-Family Dwelling 1,2008
if t ;x
This Section For Official Use Only
Building Permit Number:' Date Applied: . - Y
Building Commissioner/hupeetor of Buildings Date
_`SECTION 1:SITE INFORMATION
1.1 Property 'T /ACC / ( 1.2 Assessors Map&.A4raelMl mHers,
1.1 a Is this an accepted street?yes_ no - Map Number - - 1 Number
13 Zoning Information: IA Property Dimensions:
Zoning District, Proposed Use Lot Area(sq R) - Frontage(R)
1.5 Building Setbacks(it)
Front Yard d 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 13 Private❑ - Zone: _ Outside Flood Zone?Check if csl'] Municipal O On site disposal system
4 SECTION 2 ,PROPERTY OWNERSHIP' F
2.1 Owner of Record: .
Er,c �� ���X
.. Hare�_ "
Name(Print) - Address for Service:
Signature Telephone
SECTION 3:DESCRH'TION OF PROPOSED WORKZ(check'all that apply) •*• -�=�New Construction❑ Existing Building❑ Owner-Occupied O Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition " '0* Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed WorV: 5 4.r. !'
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only.
Labor and Materials r
1.Building `u '$ "' L.Building Permit Fee $ Indicate how fee is determined::;
❑Standard City/Pown Application Fee
2.Electrical: . ' t, ,$' r .
❑Total Project Cost'(Item 6)x'multi
,06r' x '
3.Plumbing $ 2:Other Fees: $ ;
4.Mechanical (IIVAC) $ List:
5.Mechanical (Fire $ „
Suppression)
Total All Fees:
Check No. Check Amount: Cash Amount
6.Total Project Cost: (o ❑paid in Full ❑Outstandmg Balance Due
I A,L,LLX-,--p Qo( � ZB
-To ITT L.Wl
f
SECTIONS: CONSTRUCTION SERVICES-
.w.x...,Ts.-.v» do lTltT�R'a �li�t
& `Licensed Coust;-c`iiou Supervisor(CSL)
0:3 -M A CC, License Number Expiration Date
Name.of CSL 11o1(.r - U
3 Marl St List CSL Type(see below)
Address Salem MA 01970 `.Descr
U Unrestricted u to35 000 Cu.Ca Ft
Signature /� R Restricted 1&2 FamilyDwelling
M Masonry Only
RC Residential Roofing Covering
Telephone - WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) - y -O
Alliilllic wP,Bthe zatiofl HE''X°�e R on Number
Company Name edff m "
Address 1S�iem MA 019 -
Expiration Date-
Signature - 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 o e building permit.
Signed Affidavit Attached? Yes....:..... No...........❑ '
SECTION 7a:OWNER AUTHORIZATION TO BE COWLETED`WHEN
OWNER'S AGENT OR
CON TR,ACTOR APPLIES FOR RUILDINGI PERMIT '
r 111M !r�1 as Owner of the subject property hereby
authorize C!, C �a J_il to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner - - - Date "
SECTION 7b:'OWN ER'OR AUTHORIZED AGENT DECLARATION -
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and .
behalf.
Ec r L
Print Name
Signature of Owner or�Agent' _ Date
(Signed under the vains and penalties of
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 M.G.L.c.142A.Other important information on the HIC Program and "
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"