432 ESSEX ST - BUILDING PERMIT APP ;a — ----- The C'onunonw'etdth Of MaSSaCh USCIIS
Board of Building Regulations and Standards CITY OF
MassachuSctts State Building Code, 780 C NfR SALEM
�` vsed.11ur'nll
Building Permit Application To Construct. Repair, Renovate Or Denutlis a
One-or Two-Funlilt DiveMi{tr
This Section For Official Use Only
Building Permit Number: Date Applied:
• z4. r
Building Official(Print Na ne) Sigr to 10 Uutc
SECTION I: SITE INF � ATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
I.la Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Tuning District Proposed Use Lot Area(sq ll) Frcmtage(It)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.§Sa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check iY 'es❑ Municipal❑ On site disposal system ❑
SECTION I: PROPERTYOWNERSNIPt
1.1 Ownert of Record:
�s 41� 6G d , 1,/ Su /c h !h,1 Of 9 �C7
Mane IPnnt) (Uq,Slate,T.IP
cna Es5&r 5� tIV4 IR- �i ?e 9,43 Ga--J
No.and Street Telephone &nail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairsis) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work-: T�s �[ .0 o, t%e- S v� ...�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
item Estinmted Costs: Official Use Only I Labor and.\Interialsl Y
I. Building S I. Building Permit Fee: E Indicate how fee is determined:
'. Electrical S ❑Standard CitytTuwn Application Fee
❑Total Project Cost'(Item 6)x multiplier .x
?. Plumbi°g S 2. Other Fees: S ----
J. \IcOlanic:d ill\':\C'1 S List:
I ;. ,\fcchanical (Fire
� Supvcssion) S TotaI All Fces: --------
n, Total Project Cost: S� Check No. __—('heck Amount: _- -- (',uh:\n,ount:
3 ❑Paid in Full ❑Outstanding Balance Due:
Jor/,�
f
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number --' --- F\piration Male
N;une oI CSI. I)older �—
List CSI.1)Pe(see below)
I)PC Description
No. and Street
l i I inrestricleJ Olinditi;TuO to 35,000 nl, Il.l
_ R Restricted I,2 Family DPe1111
bl Mason
RC Rw lin t Co%erinii
----. AS Window:md Siding
SF .Solid Fuel Burning Appliances
Insulation
l cic hone 1[nwil address U Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Registration Number lispiralion Mulc
I IIC Company Name or I IIC Itegistrunt Name
No. and Street Email address
City/Town. State,ZIP Tcle 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 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize a, 6�/
,B \ /
to act on my behalf,in all matters relative to work authorized by this building pe mit application.
sr/ /
Print ner's Name(Electronic Signature) Drate
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,1 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.
Print 0ttnor's or:\uthorired,\gent's Nance 117Iectronic Signature) Dale
NOTES:
I. An Owner who obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor
(nut registered in the Hume Improvement Contractor(HIC) Program).will no have access to the.arbitration
program or guaranty fund under M.G.L.c. I42A. Other important information on the HIC Program can be found at
tt%t+t n,,+.. •.•,+t , :.I lnfonnation on the Construction Supervisor License can be found at kt wt.inosz Jp.
2. When substantial work is planned,pros ide the information below:
Total Iloor area(sq. n.) _ I including garage, finished basement attics.decks or porch)
Gross living area(sq. 11.) _ Habitable room count
N'uniberoffireplaces_--. Number_ _ _ ..._ N'umberofbedrooms
nis
I\IpethS
(iY.whitgr:\,sicim . ... -- INumb`rofdeckslptrches
Proicet Square FoolagC"Illlw he,ub,tituted for"total Project Cost-
J