358 1-2 ESSEX ST - BUILDING JACKET S'
CiC � 23
The Commonwealth of Massachusetts - -- -
I Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALE\I
Lb+ Herr.r�•d Ilur 111//
Building Permit Application To Construct, Repair. Renovate Or Demolish a
One-or Two-Fcrmilt,Drellhkq
/ This Section For Official se Only
1 / Building Permit Number: Date pplied:
�ure 8
Building Olticial(Print Mane) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property A dr ss: 1.2 Assessors Map& Parcel Numbers
3S )�z 6SSeX ST
I.la Is this an accepted street?yes_ no Map Numher Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Coning District Proposed Use Lot Area(sy Ill Frontage(Il)
1.5 Building Setbacks(R)
Front Yard Side Yards
Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Chek ir.—M n site disposal s stem ❑
s SE7C—TION2: PROPERTY OWNERSHIP'
2.1 Owner of � . /� /1� 1/Kff S • f ! r/?o�
N;unc(Print City,State,ZIP
Nu.and Street Telephone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK](check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) 19 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work: ai a oi' /o,., o y 4KAKCQ r is S X,5
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(ILabor and \Iaterials) y
I. Building S g00-&0 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard City?own Application Fee
Cl Total Project Cost(Item 6)x multiplier --_x
i, Plumbing S 2._. Other Fees: S
a. Mcchanic;d 1B\':\C) S List:
s. .\lechmtical (Fire — ------ — -
tiu>> essiunl S Total \It Fees: S
6. Total Project Cult S a80. Ol7 Check No. Check:\mount: ----Cash Amount:___.. .._
0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(C'SL)
J` ------ —i -- 7
License Number Fap iralion Mae
N;unc ol'l'SI. Iluldcr ------ 1-
_Jr G,IuSL.. Rt I ----_-- --___-- Listl'SL I)pe(see below)_--�—
No. and Strect Type Ucscriplian
Q LI I lurestricied(Iluildin is Lit)to 35,000 cu. IL) t
_�A.fPf f hwt PAC q — l�k_-_ R Restricted LK)FamilyDeellin g j
0"NAmil.Slate,ZIP NI Nlasunr
RC Rooting C'ovcrin t'
WS Window and Siding 'd
SF Solid Fuel Burning Appliances
C, iy7G-366e yzm 014W 175 yR lrcr.cak I Insulation
'I viviihone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 3 a 9tl 2 - 2ou
&z cL eusr ceLge�� mg r ( `n e-f ��� I IIC' Registration Numhcr licpirotiun Due
I IIC�onr'p(f�ri'imt4lcC t2rIIIC 7 Name V-ell
W 40%
No. oW Email address
City/Town. State,ZIP "felt 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 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 Udlyt yrk WIU604�(
to act on my behalf,in all matters relative to work authorized by thi ilding permit application. f /
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
contained in this application is true and accurate to the best of my knowledge and understanding.
K evivle2i, �40(-01y 7
Print Owner's or Authorized Agent's Name(Flectrunic 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 NI.G.L.c. 1 a_'A.Other important information on the HIC Program can be found at
tt,tts nnn,.�,n.� r.i Information on the Construction Supervisor License can be found at u;v,s.�A dp,
2. When substantial work is planned, provide the information below:
Totai fluor area(sq. ft.) (including garage, finished basemenCatties,decks or porch)
Gross living area(sq. 11.) __ _ Habitable room count
-------------- - -----
Number of fireplaces `umber of bedrooms
Number of hmhruunts Number of halt'hadu
I')lie of heating s)stem --- Number of decks, porches.
1")peofcaulingi�stem _ _. Fncloscd Open
1. "I'olal Project Square Footage"may be substituted for-Fo(al Project Cost"