128 ESSEX ST - BUILDING PERMIT APP (003) The Commonwealth of Massachusetts
77 Town of
Board of Budding Regulations and Standards
Massachusetts Stale Building Code, 780 CMR, Tx editio lommavw
n
i� Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1 ►
One- or Ttro�nilc Duelling
This Section For Official Use Only
Building Permit Number' 1 Date Applied:
Signature:
Building Commissioner/ins of Buildifngs Date
SECTION 1:SITE FORMATION
1.1 Property Ad ress: r� 1.2 Assessors Map& Parcel Numbers
�a? � �SSfx Sf y
I.1 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 R) Frontage(n)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1,6 Water Supply:(M.G.I.c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if Ves0
SECTION 2: PROPERTY OWNERSHIP'
20 Ot ner'of Re Drd: 1
U rrcf sf ✓ !U n ?� ,SP�G moo!
Name ring Address for Servicy`,
wknselffne
Si azure Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: :7a=0eiY
Brief Description of Proposed Work':
7b =P f a 3 d x�/o �no7a 7�n
� ns?r 1 e-a` O
SECTION 4: ESTIMATED CO STRUC ION COSTS -
Item Estimated Costs: Ofllclal Use Only
Labor and Materials
I. Building f Q ,S 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical f ❑Standard City/Town Application Fee
O Total Project Cost (Item 6)x multiplier x
3 Plumbing f 2. Other Fees: S
4. Mechanical (HVAC) S List:
5 Mechanical (Fire S
S Total All Fees: S
u res.ston
Check No. _Check Amount: Cash Amount:
6. Total Project Cost: S /07s ❑ Paid in Full ❑Outstanding Balance Due:
ri
V 0
C� !� b 3f�
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor ICSL) 4 Q, /9 ,7
Q //T e'/ L.crn.e Number Es o uaun i0ite
L,.t CSL Type Iwe below)
T I Description
A s U Unrestricted(up to 35,000 Cu, Ft.)
R Restricted 1&2 Family Dwcllm
5ignamre c M 1 Masonry Only
RC Residential Roofing Covering
Telephone WS Residemtal Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Dale .
Signarurc Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 152.S 2SC(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........... O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, /U S Q'1 1-�W/Leti tea— _ _ as Owner of the subject property hereby
authorize I�G a wJ 0n o.vs,tj Con 't to act on my behalf,in all matters
relative , work authorizedorized by this
�8 permit application.
Ca— iL—/D
Si nature of Owner Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
rbehalf
is Owner or Authorized Agent hereby declare
the statements and informati on the foregoing application are true and accurate, to the best of my knowledge and
C/!A "
cc
Signature of Owner or Authorized Agent Dates
Signed under the pains and penalties of perjury
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 rig(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 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/amics, decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of Fireplaces Number of bedrooms
Number of bathrooms Number of halfbaths
Type of heating system Number of decks/ porches
Typeof cooling system Enclosed Open
3. "Total Project Square Footage"may be uhslituted for 'Total Project Cost"