45 FEDERAL ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
ALELM
Massachusetts State Building Code 780 CivIR SdXfar
1 g Revised Mar ZOl l
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Divelling
This Section;For Official se Only. -
Building Permit Number: Date pplie&;.
S1 13
Building Official(Print Name) _ : Signature Date
SECTION 1:SITE INFORIVIATION
(.PPrroVdVd�re�s"+ 1.2 Assessors Map & Parcel Numbers
1.1a 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❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2:; PROPERTY OWNERSHD?L '.
2.1 Owner of Record: I V ®`p 7
6
Name(Print) �` City,State,ZIP
No.and Street Telephone " " Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building Owner-Occupied ❑ 1 Repairs( Alteration(s) ❑ Addition ❑
Demolition Cl Accessory Bldg. ❑ 1 Number of Units__ I Other ❑ Specify:
Brief Descriptit of Proposed 1Vo k': - r d 2-S C2
i
,u O no
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: I.
[tern Official Use Only- ..
Labor and Nlaterials
I. Building 320
(�.� 1. Building_Permit Fee:.S Cridicate how fee is determined:
❑ Standard,City/'Gown Application Fee
2. Electrical 5 ❑'Dotal Project Cost'(Item 6)xmultiplier x
3. Plumbin; 5 2, OtherFees: S
4. \(zchnnictl (HV:\C) 5 List:-
i. Mechanical (Fire
suppression) $ Total :All Fees:S
—� Check No. Check AtnoUnt: Cash Autouut:
fi I'otal Project Cult S30 6wr ( 0 Paid in Full ❑ Outstanding Balance Due:
r t
sEcTION 5: CONSTRUCTION SERVICES
5.1 Construction/Supervisor License(CSL) /O`��Co� --7_ t /L�
�„�.,e� /L.� License Number Expiration Date
Da—te
NNa of arnneCS� v"LHold`eyyr-- vv
List CSL Type(sae below)
Type Description
No. and Street
0 U Unrestricted(Buildings u to 35,000 cu. ft.)
l_UJ oC R Restricted 1&2 Family Dwelling
Ci a ate_,ZIP A Nlasonry
RC Rootin Covering
WS Window and Sidin•
SF Solid Fuel Burning Appliances
I Insulation
'1'ele hone 1,� Emait address D Demolition
5.2 Registered Home Improvement Contractor(FIIC) {lnG?�2 . —0
W11� HIC Registration Number Expiration Date
I IC 3 pony nine or F IC Remlt Name j
i
No. an St t Email address
-��,tn� yt�d gr�.�d6��w1s
Ci /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
I, as Owner of the subject property,hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER' 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.
Print Owner's or'\Iltl"rlZed:\gent's Name(Electronic 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 M.G.L. c. 142A. Other important information on the FIIC Program can be found at
www.m;us.eovoca Information on the Construction Supervisor License can be found at www.mass.•_�:dEv
2. When substantial work is planned,provide the information below:
Total floor area(i(l. ft.) (including garage, finished basement/attici, decks or porch)
Groii living area(ski. it.) _ Flabitable room count
Number of tireplaces.-__ Number of bedrooms --------
Number oCbathrooms Number of halL'baths _
tyPC of heating iyitant _ --- -,---_----.-- Number of decks/porches
I'ti pa of cooling syacnl -.----------__,_--- ElIClnietl
�. "Total Ill UJCCt1tllIIIIVI'oot:l�C' Illay be illbittflltMfOl"'1orA P rl lject('U9t" �-