0356 ESSEX ST - BPA-12-103 e I�
.a The Commonwealth of Massachusetts
,, Board of Building Regulations and Standards CI'I'1'OF
i9 Massachusetts State Building Code, 780 CMR tiAL[�I
L Rerised.tlur 011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Furnilt Duvellinsr
Phis Se, un For O �ial a Onl
Building Permit Number: ate Ap ied: _ D
Building Official(Print Name) Sign tur / Date
/
SECTION I:SITE INFOR ION
1.1 Property Address: 1.2 Assessors Map& Parcel Nu=Yud
3Si, ; d d
1.la Is this an accepted street?yes_ no Map Number Parc
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area is
11) fron
1.5 Building Setbacks(ft)
Front Yard Side Yards Provided Reyuircd Provided Required
1.6 Water Supply:(M.G.I.c.40.§54) 1.7 Flood Zone Information: 1.8 SewageJ31sposal System:
Public 9� Private❑ Zone: _ Outside Flood;Check if ycs0 Municipal t'J On site disposal system ❑
SECTION3: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
iU(/1/awxNC -mrtQvrvKrr�[� SfiGLlrlM! 6i9?0
,one(Pr Ut),Store,LIP
No. and Street Telephone Fount Address
SECTION 3: DESCRIPTION OF PROPOSED WORK"(check all that apply)
New Construction ❑ Existing Building Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ I Accessory Bldg. ❑ 1 Number of Units_ 1.Other ❑ Specify:
BriefDescriptionof Proposed Work':S�1,'r0G Qi3AsLe)F0[, AV64' 4e12!.r Ua5lokREAAv-1nA'xl
=c
• ugwrSEC case
SECTION 4: ESTIMATED CONSTRUCTION COST
Item Estimated Costs: Official Use Only
Labor and \laterials l n y
I. Building S r%8 1. Building Permit Fee: S Indicate how fee is determined:
'. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier __ x
1. Plumbing S 1. Other Fees: S
a. .\Icchanical III\':\('1 S LisC.__ _
S, .Mcclimuc;d (Fire S - --
Su>>ression) Total All Fees: S
C'hak No. Check Amount: C ash A Mllnl:
v, Total Project Cost: q rr d — ------ -- - -
J 0 Paid in Full ❑Outstanding Bahmce Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(C'SL)
1 y
License Number Fxpifatiog Dale
Name of C'SI. I Iulder D ////
/3 �Q�� �� List C'SI.1)pc(see below) rc,�Gt�S_4 _
—/_3 Street ----- .I.`.PC Description
nq// CI t Inrestricted(INildin s ti to 35,000 cu. 11.) -
I �IVI(ob R Restricted I&? FamilyDwellin
C'ity/foen,St; c.ZIP M M1lason
RC Roolin Co%crin
W'S Window and Siding
SF Solid Fuel ?Burning Appliances
2Cj73I'1 C-�� I I Insulation
"fete hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) —'/01 77'l
GIy�,, QjES I IIC Regutral un Number ISs ruin u Dote
III 'Camag�n) Name or I IIC Registrant Name
SSK.wcn N01 slay
No. p Ed Street Email address
�irPz�G/ irtA al9/�n 9795 /'� /l�9
City/Town. Slitte.ZIP "relc hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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 Issuan a of the building permit.
Signed Affidavit Attached? Yes .......... Ild 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.
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
contat ed in this application is true and accurate to the best of my knowledge and understanding.
Print D\Nner'i or Atahorized,\gent',Name(Flectrunic Signature) at
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 M.G.L.c. 142A.Other important information on the HIC Program can be found at
n".�;jm 0._ i Information on the Construction Supervisor License can be found at nrisS can -,Ili;
2. \?'hen substantial work is planned, provide the information below:
Total fluor area(sq. ft.) _(including garage, finished basement'attics,decks or porch)
Gross )icing area(sq. 11.) _-- ._ --—_--- _ Habitable room count _-_------_.--- - ---._ _
Number of fireplaces _ Number of bedrooms
Number of bathrooms Number ofhalfb;nhs
1)pe of heating s)stem _ _ __---.- Number of decks, porches
I\lie ofcoulingSySlent LncloscJ ___Open
i '•Tolal Project Square Footage-may be substituted Pitt"folal Projcct Cost'