35 ESSEX STREET - BUILDING PERMIT APP 1� The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
r3 t>F SALGM
Massachusetts State Building Code, 730 CMR, Th edition
Revised January
ey
Building Permit Application'fo Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
i T4iog>Ktion For frrcial Use Only
Building Permit Number: I ate Applied: 14� •r
Signature:
Building Commissioner/Inspire, rot' toil 'n Date
SECTI 1: SITE INFORMATION
Ll erty�ddress: 51
j 1.2 Assessors Map At Parcel Numbers
I.la Is this an an accepted epted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sy 11) 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.I.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 if yes❑ P p y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownert of 1�.ecor 3
d: A
d o� �-
Name(Print) Address for Service:
r'�( `? �, S 6' 50 Sv
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) i Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Descriqtion of Proposed Work':
�-PsJ�_-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1. Building S 0 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cush(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S Total All Fees:S
Suppression)
Check No. Check Amount Cash Amount:_
6. Total Project Cost: S�2 ,,'JD'O ❑Paid in Full ❑Outstanding Balance Due:
/9 L _707� (5� � % L
C'4/ J"
SECTION 5: CONSTRUCTION SERVICES
5.1 Lie en ed Construction
,,Supervisor(CSL) i^ S C/ G � aj ) 'f,-) ) —(3
, 1-', yre ✓ate f SO License NumherD I:Npimtion Date
Name�oI*CSI.- Il�d/ / List CSL Type(see below)
Tr Description
Address unrestricted u to 35,000 Cu. I'c)
o It I Restricted 1&2 Family Dweilin
Sign + t� g o L, O g hf Mason al
RC' Residential RoofingQrrerin
Telephone WS I Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
U 1 Residential Demolition
-.2 Registered Home ImprovementFontracto (HIC) ( 6 y 9
1 (��,rsd (� G , _, Lac 4l C S
I IIC Company Name or HIC Registrant Name Registration Number
s3 9 r-- rtrA �o <�� LY
Addressl 5 $ 3n b 0 9 S a
Gs mtion Dale
Sig urc 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 ..........;ty< No........... ❑
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.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, 5 ,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.
Print Name
Signatur of vner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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(IIIC)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 and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I I0.R6 and 110.115, 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.) Ilabitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half7baths
Type of heating system Number of decks/porches
Type of cooling system Fnclosed Open
3. "Total Project Square Footage"may he substituted for"Total Project Cost"