54 ESSEX ST - BUILDING JACKETr
f�'•�G 1
The Commonwealth of Massachusetts
' Board of Building Regulations and Standards IMSPECTION L SFcgy4C&S'
Massachusetts State Building Code, 780 CMR SALEM
�i01S M�Y I
09 Building Permit Application To Construct,Repair, Renovate Or emolls aease "�L'�o�!
� a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Appli
Ln Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
.sZ{ eSS,�_)C cSf'.
1.l a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
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 10,�Private❑ Zone: _ Outside Flood Zone? Municipal CLOn site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
Rio,a e-16-1.1 S�c%^. /Y 14 U ! g ?Q
Name(Print) City,State,ZIP
5 Y essex S%+ c F (y17—SrBd—Go2 P& m'So unc[ k /4n a) alua • ca n
No.and Street Telephone Email ddress
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work: ep rn n I
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1. Building $ J7 000 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 (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 1�006 ❑Paid in Full ❑ Outstanding Balance Due:
St�lvo 1--o (z) ,r 5�5 5I21
^ SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
Uµo� 4,_ AW acita- -41 License Number Expiration Date
Name of CSL Holder
!q
List CSL Type(see below)
,4/6;air S1-
No.and Street Type Description
5d/4,fK ff -F 01 q 7 U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
g7&a/u I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
t HIC Registration Number Expiation Date
HIC Company Name or HIC Registrant Name
/sf 4./6ie" SY- • KOd IoueLr,4' gD 4a(-Gct�
No.and Street
a �.e,'" _ H� n ) R '7t' 97g'01/0-9 fZl Email address
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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No... ..... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize )56co-v 4- H e1p,( a c6
to act on my behalf, in all matters relative to work authorized by this building permit application.
Mi'; 19L10_� o,r/s/is
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,1 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.
!) u cr-0-_ M a e-krA do OJ h��/ 5—
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. t42A. Other important information on the HIC Program can be found at
www.mass.gov/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 halfibaths
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"
PUBLIC PROPERTY
DEPARTMENT
K. ORMARL
MAYOR
120 WA"NcmN S%rKEsr•S"jam.- ,y uyAcHLsh-j rs 01970 -
TEL•978-745-9S95 0 PAX'978-740.9846 .
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDIN
1.0 SITE INFORMATION
Location Name: Building:
Property Address:
Property is bcated in a;Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address: J!2f C�c 57
Telephone: 6 q ; / 3 9
3.0 COMPLETE THIS SECTION FOR WORK IN PYISXING BUILDINGS ONLY
Addition Existing orb
RenEin
E ENumber of Stories Renovated
Chae New
Demolition
Existing ^-� 600
Approximate year of Area per floor (sf) Renovated
construction or renovation goe)
of existing building New
Bdef Description of Proposed Work:
-
Mail Permit to.-- -- — —
What is the current use of the Building?
Material of Building? �Oo� if dwelling.how many units? —
Will the Building Conform to Law?
Asb
V estos? �a�E
Architect's Name Ac(D N E
Address and Phone
Mechanic's Name u r-
�EU��L�
Address and Phone ue" vog f
Construction Supervisors License# �''S �HIC Registration#
00 Permit Fee Calculation I
Estimated Cost of Project$ Estimated Cost X$7/$1000 Residential
Permit Fee$
Estimated Cost X$11/$1000 Commercial
An Additional$5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penally of perjury �
X ( a = .
Date S ol0
1
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