128 ESSEX ST - BUILDING PERMIT APP (002) r � CK 23�-7 � ZSDO
The Commonwealth of Massachusetts INSPECTIONA $E / �
( � Board of Building Regulations and Standards SALEM
\�U�3[ Massachusetts State Building Code, 780 CMR 1��5 riQY 3 $ iZdQ2dll
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One- or Two-Family Dwelling
,:ThreSectronForOfficialUseOi(lyr.;t�+k;x'
BuildrnePermttNumber r ,* u =
Date pphed r ,L z h,
2 7 s i x e00, {
t' W`€ sk �. y P tN'.}p r if "F,p x '` —.1 ✓ �aL
Buildmoa Officila (Prmt Narne) 'C'� - ' Date k'�'• Slgnafiie �m`
t4 ;dr „. `. 3 SECTION,1 SI_TE'INFORMATION v r ,'x�' „: �a�:
t (� 1.1 Prop?SL�erty Address: 1.2 Assessors Map&Parcel Numbers
� SSeX .S/"
( l.la 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 Yazd 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?
Check if yes❑ Municipal❑ On site disposal system ❑
- SECTION2 PROPERTY,OWNERSHIP',,,. $`.,,{
2 Orr ert of Record:
AoQ 71ody �sSeY /�dr eum S��Crrt f /
Name(Print)/ City,State,ZIP
AW �sSGrc st 978'-7yS='S�
No.and Street Telephone Email Address
V ,f SECTION 3 DESCRIPTION�OF PROPOSED WORK (clieck'all that
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition 0
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other Zl Specify:
Brief Description of Proposed World:
70 f- i7ecP a. so -yo �`n,DORC< u TTwf osi 1/1 1-T-
e oVe Of) aS /Y
SECTION 4:EST TED CONSTRUCTION COSTS ' E yA _
Estimated Costs: � ,^' Fh 4j rfl ,v , ,,,
Item Fc x'. �` a i-Official Use Onl '`'
(Labor and Materials .+,
1.Building $ 1 `Buddin i PermrtFee $ w+ Indreatehow fee rs determined:
2.Electrical $ 3�D ❑Standar tCrty/Tov n Apphcanon FeeQ `
❑Total Project Cost'(Item 6)x n ulnpher x
3.Plumbing $ 2
t
4.Mechanical (HVAC) $
L1S tieus i
5.Mechanical (Fire
Suppression) $ Total'AlIFees $ :s
6.Total Project Cost: $ r Check No: Check Amount € K Cash Amotmt 1 x
�j� ❑Paid in Full f ❑Optstandtn alance Due
Pllp 14-� S�2a7b
I
NI
SECTION 5: 'CONSTRUCTION SERVICES`� ;_�, s
5.1 Construction Supervisor License(CSL)
�9ar�lc /7
14 �R���/et_ License Number Expiratto Date
Name of CSL H lder
List CSL Type(see below)
.33 al 15,z C( R cP >,v -;
No.and Street TYPe#, � , ' ;DescPpnon � "`'� r
. .».� t. q
-Vm e 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 Sidin
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 gistered Home Improvement Contractor(HIC) /j �a�a
C!a TR4//z� e tr t! �r
HIC Registration Number xpir tion Date
HIC�3 om aaale 7 Re�tr53n Name
No. n Street' 77 QQ�, Email address
- O/n/ M/4
City/Town,State,ZIP Telephone
is SECTION 6 WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M G L4'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 .......... fe'I-' No...........❑
xSECTION 7a'OWNER AUTHORIZAP�I,ONTOBE COMPLETEDWHIA ' c y
".v .
jsOWNER'S AGENT OR CONTRACTORAPPLIES FOR BUILDING PERMIT
I,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.
SeC 411aekld 6M A 447c -
Print Owner's Name(Electronic Signature) Date
°SECTION.7b:OWNER i3ORAUTHORIZED'AGENTDECLARATION
By entering my name below,I hereby attest tinder 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 tmderstanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) ate
_... ,d ; . - .ter ,,,;' . .,a.,.--° x ti `'f_NOT'E6 4 7�s-� VQ,
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.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
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"