343 ESSEX ST - BUILDING PERMIT APP 3m
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards
Nlassachusctts State Building Code, 780 CMR SALEM
Revised.tJnr 1011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dve!(ing
This Section For Official Use Only
Building Permit Number: Da plies:
Building Official(Print Na e Stgna rte
SECTION I:SITE 1 FORi41AT10N
1.1 Property Address: " 12 �i /' 1.2 Assessors Map3r Parcel Numbers
I.1a Is this an accepted street?yes no "� Map Number Purcei Number t�
1.3 Zoning Information- LJ Property Dimensions:
Zoning District Proposed Use Lot Area(sq tt) Frontage(11)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check ifyes❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownert of Record: j -W K0I ( ����
yhmc(Print) I� Cfi '�Ci City,State,ZIP l l r
No. and Street Telephone Email Addskss
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Cl I Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Oroposed Work':
ova o i 4- G D
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building 3 1. Building Permit Fee:S Indicate how fee is determined:
❑Sta dard City/Town Application Fee
2. Electrical S
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing .S 2. Other Fees: S
4. Mechanical (FIVAC) S List:
5. Mechanical (Fire S
Suppression) otal:\II Fees: S
n C neck No._Check Amount: Cash Amount:
6. Total Project Cost S ODD Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor Liccnse(CSL) .
License Number Expiration Date
Name of CSL Mulder
List CSL'fype(see below) '.
No.and Street Type Description -
U Unrestricted Buildings Lip to 35,000 cu. 11.)
R Restricted 1&2 Runily Dwelling
Cityfrown,State,ZIP ibt Nfasonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
1'cic hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State,ZIP 'rele hone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION-
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
cunt ined in this applica(yefi is trdeland accurate to the best of my knowledge and understanding.
Print vner's or VathoriAd Age t Name(Electronic Signature) Date
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 not have access to the arbitration
program or guaranty fund under bLG.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 waow.masssgov'de
2. When substantial work is planned,provide the information below:
'total tloor area(sq. eJ (including garage, finished basement/attics,decks or porch)
Gross living area(sq. tt.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number ofhalf/baths
Type of heating system Number ordecks/porches
Type orcooling system Enclosed Open
3. "rotal Project Square Footage"may be substituted for"'focal Project Cost"