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21 FAIRVIEW RD - BUILDING PERMIT APP (003) The Commonwealth of Massachusetts aSPE TIONA�SdfRVIC S Board of Building Regulations and Standards p Massachusetts State Building Code, 780 CMR SALEM IOIb Ark W AAr D14 Building Permit Application To Construct, Repair, Renovate Or Demolish a r One-or Two-Family Dwelling ( This Section For Official Use Only n Building Permit Number: Date Applie Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers I Fa1Py)ew- Rd 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Or Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑ Check if ves❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: , Tow-iu 0 Vkj P_ /97P7 Name(Print) City,State,ZIP a l r0.t V`1/I-EL"t A No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORle(check all that apply) New Construction❑ Existing Building 41 Owner-Occupied Krt Repairs(s) xrt Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify: Brief Description of Proposed Work': V43,,,,92 J e J f3,15.,, ate; 3�T��l-� Rw�L..rv_ o,ng�� iTPLg-4W,::TJ 14 U'ac'1 T�i4 AA J. FlYftln� .w SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 0 00 "° 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ a©OCR O G ❑Standard City/Town Application Fee ❑Total Project Cost (Item 6)x multiplier _ x 3. Plumbing $ 06600 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ y('Ov J ❑Paid in Full ❑Outstanding Balance Due: 0 l l LADL v SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder -} List CSL Type(see below) U Type Description No.and Snee((t''/ti/N I TO r7S 'F' �3 U Unrestricted(Buildings u to 35,000 cu.ft.) MCA 9 R Restricted I&2 Family Dwelling City(Idwn,State,ZIP M Maso RC Roofing Covering WS Window and Siding I SF Solid Fuel Burning Appliances f^„sia�CRPN7`uu aDI ,Cnwt I Insulation Telephone Email ass D Demolition 5.2 Registered Home Improvement Contractor(HIC) /off sra3 (t s.,t/I,tx, 4.44 r Rou.n ,. IA� 'C HIC Registration Number Expiration Date HIC Company Name or HI egistram Name y a cn�, ,Pes, �o�li�L, c, No.and Street E mailyaddress City/Town, State,ZIP Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 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 x 1,as Owner of the subject property,hereby authorize 1`pYi_Qvi-r 0 y YJ`e_ to act on my behalf,in aa�lll matters relative to/ ork authorized by this building permit application. Print er'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. 1R,56 ,T 7),Ae, )- a/- )Ol/n Print Owners 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 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 www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dns 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) 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 for"Total Project Cost'