173-175 ESSEX ST - BUILDING PERMIT APP The Commonwcalth of Massachuscus
A
Board of Building Regulations and Standards
.Massachusetts State Budding Code, 780 CMR. 1'"editionBuilding
Building Permit Application To Construct, Repair, Renovate Or Demolis
One. or Tuo-Farrah•Duelling
This Section For Official Use Only
Building Permit Number Date Applied: Gtj'
-Signature:
Bud in mmtssioner/Ins t ings Date
ION 1: SITE INFORMATION
1,�Pl�pe;y ddres* 1.2 Assessors Map dt Parcel Numbers
L I s is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Arc&(sq II) Frontage III)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rev Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Munici al O On site disposal s stem O
Public O Privarc O Check if esO P Y
SECTION 2: PROPERTY
OWNERSHIP'
Ow jer of Record: 1 �O i� t �� ASir✓ r I��lf �P4 dlrrt(�
Name(Print) p Address for Service
7O1 2
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKS(cheek all that apply)
New Construction O Existing Building O 1 Owner-Occupied O Repairs(s) O 1 Alteration(s) O Addition O
Demolition O 1 Accessory Bldg.O Number of Units Other O Specify!
Brief Desc tion of Proposed Works: -/.Jag•� c r- ��
Dh f n
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Offlclal Use Only
Item Labor and Materials
1. Budding f 1. Building Permit Fee: S Indicate how fee is determined:
O Standard City/Town Application Fee
1 Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: f
4. Mechanical (HVAC) S List:
S Mechanical (Fire S Total All Fees: S
Su ression
��y n'� Check No. _Check Amount: Cash Amount:_
6 Total Project Cost: S 3 U v ❑ Paid in Full 0 Outstanding.Balance Due:
t
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) y-r� Z Cf
r. ` 1
7
• ' Li.cn.e VumDer E%puauon Date
N.4roc of CSL-`I)gL s S - rl//T List CSL Type lace hrWw)
ea, I ( Description
A ress
U Unrestricted(up to 35,000 Cu. Ft.
Restricted 1&2 Family Dssellin
Signature _ M^l�d H %lawnry Only
lSi �JV RC Revdenttal Rooftn Covering
Telephone wS Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 R tered Home Im rov at ntractor(HIC)
a C r°
HIC Co N � Registration NumberLneorHlCRq
A ss G35--odqC) I Expiration Date
Signty Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 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$ uilding permit.
Signed Affidavit Attached? Yes.......... O ........... O
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 7bp:OWNER'OR AUTHORIZED AGENT DECLARATION
1, 22�e 1. Mir< 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. �M
Print t A^ ' 01
Signal Own r Authorized Agent Date
St ned 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 j�have access to the arbitration
program or guaranty fund under M.G.L. c. 1 a2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I IO.RS, 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. Fl.) Habitable room.count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfbaihs
Type of heating system Number of decks/porches
Ty pe of cooling system Enclosed Open
3 Total Project Square Footage" may he substituted for"Total Project Cost•