15 EVERETT RD - BUILDING JACKET 7
7,
-10
lalt�E_IL'�."-ERV rES,,-
'File Commonwealth of lvla'ssachu SCTiotjj� Is CITY OF
Board of Building Regulations and S SALEM
Massachusetts;State Building Code,730 CIV V0
)&9jsedA1ar 2011
13 A 4�
Construct Repair, Reno MIR�dMemolish A
Building Permit Application To Cot Rep
c
one-'or Tivo-Fainily Divelling
This Section Fbir.official Use Only
Building Permit Number, 2a!ee Ap�fied:
Building otlicial(Print Name). Signature,. Data
SECTION 1.SITE INFORIVIATION
1.1'Property Address: 1.2 Assessors Mall&Parcel Numbers
re + R d
Parcel Number
I r
Lla is this an accepted strcet9yesQ_ nq Mop Number.
1.3 Zoning Information: j.4 Property Dimensions:
Eat Area(sq�w , Frontage(ft)
Zoning District Proposed Use
1.5 Building Setbacks(R)
Front Yard • Side Yards Rear Yard
Requi 1=5 Provided Required T Provided Required` Provided
_1.6 I—Voter Supply:(M.G.I.Q 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public M Private 0 Zone: outside Flood Zone? Municipal 0 On site disposal system 0
Check lfyesG
SECT(ON2: pROpERtYOWNERSH1P!.
-i—townerl of Record:
Rune(Print) TRY,—state,Zfl!
- 611
979
Telephone EmaiFAddms
No.and Street
SECTION 3:DESCRIPTION OF PROPOSER NVORKA(check all that apply)
New Construction C3 Existing Building 0 owner-Occupied
Demolition E3 Accessory Bldg.❑ Number of Units Other (3 Specify:
Brief
A JoLtA
Ve 121 M0 A j ,
U)
jif LX L C k\.a A,v C)
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only,,
Itclil (Labor and Materials
Building Permit Fee:S Indicate how fee is determined.
1. Building @3 Per
mit %v
[3 Standard City/Town Application Fee-
r
2.Electrical S Project
C3 Total Project Cost)(Item 6yx multiplier X
r "s_ S
3. Plumbing S Qthe'2 r Fees., S
4.Mechanical (f[VAC) S List,ist..
za
5.Mechanical (Fire Total'All Fees::S�
Stipp e ssion) z
Check No. Check Amount:—Cash Amount:
6. Tot;,j Project Cost: S Ya,3 Cl Paid in Full [I Outstanding Balance Due
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12
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SECTION 5:,CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
Expiration Date
WVE� License Number
Name of CSL Holder I . 11
List CSLType(see below)
U��l YN 0 's Type. Description
No.an et
d, U Unrestricted(Building!ug to 35,000 cu. R.)
1�er,4 ;A, M G-V R.
Cayrrowrk,state,zip -�J IM IMMOMY
RC Ranting Covering
WS Window and Siding
r SF' Solid Fuel Burning Appliances'
1 Igs.olitionInsulationTelephone Email address D
5.2 Registered Home Improvem9nt Contractor
A) 6 W -Pro Olt's HIC Registration Number Expiration Date
HICK y HIC Registnin Name Name ov
LtAm T
No.and S Email address
Eiii/Town,State,ZIP Telephone
SECTION 6:WORKERS,COMPENSATION INSURANCEAFFIDAVIt(k-GaLre-14 0 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 permiL
Signed Affidavit Attached? , Yes.......... No...........E3
SECTION 7atOWNERAUTHO.R. IZATION70 BE.COMPLETED WHEN;
OWNERS AGENT OR CONTRACT=:A.PPLIE9FOR BUILDING.PERMIT,
1,as Owner of the subject property,hereby authorize owls
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
r�-
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW ORAUTHORIZED AGENT DECLARATION
'
By entering my name below,I hereby attest under the pains and penalties of pe'riury that all of the information
contained in this application is true and ac to he bcst2Lpry knowledge and understanding:, I
by)
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 LLoj hive access to the arbitration
program or guaranty fund under 1M.G.L:c. 142A.Other important information on the HIC Program can be found at
Avww.mass.gov;'oc; Information on the Construction Supervisor License can be round at AAA.mass.uovldms
2. When substantial work is planned,provide the information below:
"A (including garage,finished basement/attics,decks or porch)
'total floor area(sq. ft-) 9- I I
Gross living area(sq.11.) 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 fiar-rotal Project Cost"
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