1 FAIRMOUNT ST - BUILDING PERMIT APP 452A �f 2 'S- 4-
'rile Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
' f Massachusetts State Building Code, 780 CMR SALEM
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised dlar 2011
One-or Two-Family Dwelling
' This Section For Official Use Only
Building Permit Number:
Date ied: f`
Building Official(Print N;une), te
-; Signa[.. e - Date
1 Pro err
SECTION li SITE INFORNIATION
ddress: "
s_1 �!'.�— 1.2 Assessors Map& Parcel Numbers
Is this an accepted street?yes_ no \dap Number Parcel Number
1.3 'Zoning Information: IA Property Dimensions:
Zoning District Proposed Us— -e
Lot Area(sq ft) Frontage(it)
1.5 Building Setbacks(ft)
Front Yard Side Yams
Provided Re
Require) Pvide)roRear Yard Required aired
9 Provide)
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information:
Public❑ Private❑ Zone: _ Outside Flood Zone? 1.8 Sewage Disposal System:
Check ifyes❑ Municipal ❑ On site disposal system ❑
2.1 Owners of eco d•
SECTION 2: PROPERTY OWNERSHIP'
N ,ne 1 not
City State,Lit—
>,V-:7q
it—
>,V-:79 S—4,/J7
No.v,J Stnet
Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.Cl Number of Units
Brief Descrip 'On of Proposed 1Vurk': e,a4, Other ❑ Specit'y:
� f xis s ✓ S m,,we
� r W>•l/ ary/
Cpca 6 - � l: J r
f-G• o uJ r t rr��
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials) Official Use Only
I. Building $ I. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
3. Plumbing $ 13Total Project Costs(Item 6)x multiplier ,x
/S- C'VV. 0" ?, Other Fees: ,$
4. Mechanical (11VAC) $ List:
5. Mechanical (Fire
Suppression) $ 101-11 All Fees:S
6. Total Project Cost: SU 0 J Check No._Check AmounC Cash Amount:
t ` ❑Paid in Full
C3 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES a
5.1 Construction Supervisor License(CSL) C en pi 42
Ex tau -Date
License Number
Name of CSL Holder List CSL'rype(see below)
AlType Description
No.,md StreetU Unrestricted Builnin s u l0 35,000 cu. ItJ "I
,r R Restricted t&2 Famit DWellin
I i C!Y N0 r� — M Mason
Citylfown,State,ZIP RC Roolin Covering
WS Window andSidin^
[ ( '/ SF Solid Fuel Burning Appliances
I Insulation
Email address D Demolition
Tcle none49
-
5.2 Registered Home Improvement Contractor(HIC i/i sl�
HIC Registration Number G iruti�n Date
h riST n.
HIC Compay Na c or HIC Regislmnl Name
Email undress
No.and Street —_
'tele hone
Cit /Town,State,ZIP
.COMPENSATION INSURANCE AFFIDAVIT(M.G L.C.152.§ 25C(6)),SECTION 6:WORKERS'
ith this application. Failure to provide
Workers Compensation Insurance affidavit must be completed and submitted w
this affidavit will result in the denial of the issuance of the building permit.
Signed Affidavit Attached? Yes ..........
SECTION 7a:ONVNER AU I HORIZATION.TO 1 E( I BUILDING
WHEN:
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,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.
Data
Print Owner's Na ne(Electronic Signature) -
UTtIORIZED AGENT DECLARATION
SECTION 7b:OWNERL ORA
pen (ties of perjury that all of the information
By entering my name below,I hereby,attest under the pains and
contained in this application is true and accurate to tha f st of my no ledge and understanding.
`/'//,S/t' /J ✓� Date
Print owiver's of Authorized Agent's Name(L•lecl unic Signature)
NOTES:
t. An Owner who obtains a building permit to do his/her own workram),,ur an olln' rt \havetac ess to hires an \the arbitration contractor
(not registered in the Home Improvement Contactor(FIIC)Prog
program or guaranty fund under ori the Constru other
License rtant for ation on the cin be toundtatC Programcan /Ifound at
l
, y/pt
i Information
\RVIV.mnyJ. 0
below:
'f lWhen
tloo substantial(S ti:d work is planned,provide the information udmg garage, finished basement/attics,decks or porch)
total floor area(sq. RJ Habitable room count
Gross living area(sq. 1iJ / 00�— Number of bedrooms __—
—
Numberoffirepluces ! Number of half/baths /
Number of bathrooms ' Number of decks/porches_
Type of heating system /yd__. Enclosed —Open
'type of cooling system
3. "total Project Square Footage"may be Substituted for"rot:d Project Cost"
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