224 ESSEX ST - BUILDING PERMIT APP 6
The Commonwealth of Massachusetts
t Board of Building Regulations and Standards I.OR
Massachusetts State Building Code. 780 CMR, 7'h edition MUNI LiSF .I'I'1'
SF
W Building Permit Application To Construct. Repair, Renovate Or Demolish Rrri.,cd lutm;ar
One- or Tn o-Fmnily Dwelling 1 2008
This Section For Official Use Only
Building Permit N tuber: Date Applied: '2 0 L'
Signature: =PK=
e v _ Building Commissioner/ Inspector of Buildings Date
4 SECTION 1: SITE INFORMATION
1.1 Mild ild 1.2 Assessors Map & Parcel Numbers
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 t1) Frontage on
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:
Zone: _ Outside Flood Zone! Municipal 01 On site disposal y'sal system ❑
Public❑ Private❑ Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Qwne f Record: VIA P 2«{ 00/—
Na,,,,�nj) u
Address for Service:
/
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(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: ✓f' U
SECTION 4: ESTIMATED CONSTRUCTION COSTS
L3.
Estimated Costs: Official Use Only
(Labor and Materials)
uilding $ I. Building Permit Fee: $ r Indicate how fee is determined:
tandard City/Town Application Fee
lectrical $ ❑Total Project Cost'(Item 6) x multiplier x
umbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire � !
Suppression) $ Total All Fees: $_/!(7
y heck N04-:ZCLCheck Amount: JLt9 Cash Amount:
6. Total. Project Cost: $ �U 'Paid in Full ❑ Outstanding Balance Due:
pkluv r
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL)
�P&a C; License Number Expiration Date
Namc oI C H IJer /� n List CSL T (see below)
G( 17VP,✓f' Type _L'L(
Type Description
4ddress it U Unrestricted(up to 35,000 Cu. Ft.)
•�� � I R Restricted 1&2 Family Dwellin
SignaturG/e, ' p) '7 M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel BuinnigAlillhancc Ins(allanun
D Residential Demolition
5.2 Registered Nome 1 prove nt Co tract (HIP)
T der
HIC Cody C Registrant Name Registration Number
42f /2- � -
Address �) '"")�/ '
�� .L� Expiration Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. $ 2506))
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 ..........ior 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 to act on my behalf, in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNER' OR
AUTHORIZED AGENT DECLARATION
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
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the 2ains and penalties of du
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 M have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115. respectively.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics. decks or porch)
Grass 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"