84-88 ESSEX ST - BUILDING PERMIT APP CK I Z)OC:>3
The Commonwealth of Massachusetts RECEI
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'ltl Board of Building Regulations and StandAWECTIONAL SE VICEATY OF
Massachusetts State Building Code, 780 CMR ��pp SALEM2011
Building Permit Application To Construct,Repair,RenovalOr�DCmllgh
One-or Two-Family Dwelling
This Section For Official Us94Wy
Building Permit Number: Date App ' d:
Building Official(Print Name) Signature
SECTION 1.SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
l.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(it)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Wat r Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? �f
Pub Private Private❑ Check if yes❑ Municipal0� site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner[of Record:
Name(Print) City,State,Z,
No.and Street Telepp
hone I Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of ProposedWork2: c \tw�t�St
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 5 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: bc'
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
50,rr TZ) -n&KT CAI (I
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
v�-r\ Unrestricted(Buildings u to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Coin Window
1 WS Window andd Sidin
SF Solid Fuel Burning Appliances
`11 -01Q� I I Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
y HIC Registm on Number Expua
HIC Cont any N or I CC egtstran[Name
No.and Street J
Email address
City/Town,Stat4 ZIP Tele one
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 \) \ . SQ .
to act on mi behalf,in all matters relative to work authorized by this building permit application.
9 � - 1
Print Owner's Name(Electronic Signatur to
SECTION 7b:OWNEW OR AUTHORIZED A DECLARATION 71
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.
T g-y _1y
Nor wner's or Authorized Agent's Name(Electronic Signature) Dak
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 can be found at
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dns
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" .