11 FELT ST - BUILDING PERMIT APP (002) ('�-izrntr v(o
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'Elie Commonwealth of Nlassachusetts INSPEC IONAL SERVICE
Board of Building Regulations and Standards CITY OF
SA<lL�M
Massachusetts State Building Code, 730 CNIR A 13
Building Permit Application To Construct, Repair, Renovate Or Demolish a
r� One-or Tivo-Family DtveUing
V~ This Section For Official Use Only
(� Building Permit Number: Date App 'ed:'
Building Official(Print Name). Signature• Date
SECTION 1:SITE INFORNIAT10N
1.1 Property Address: / I S 1.2 Assessors Map&Parcel Numbers
1 r
f`{1 1.I a Is this an accepted street?yes �JL no Map Number Parcel Number
i11 1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Require) 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 yesC3
SECTION2: PROPERTY OWNERSHIP''
2.1 Ownert of Record:MQ rp � t�� t Ia^�� S4lQ v� Vh y� (� I 7b
N-'�1me(Print) I_1 r City,State,ZIP
I �� 4- ST ql�- ggi- 89ao
No.and Strect Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ Repairs(s)OiL Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory BIJg.❑ Number of Units_ Other ❑ Specify: -
Brief Description of Proposed Work":
�f-r'uC f rA �L e
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S a I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2, Electrical S ❑Total Project Cost'(item 6)x multiplier x
3. Plumbing S 2`? Other Fees: S
4. Xiech"mical (hIV;\C) S List:
5. Mechanical (Fire ,� Total All Fees: S
Su ression)
Check No. Check Amount: Cash Amount:
6. Tutal Project Cost: S �j J ( a 8— ❑Paid in Full ❑ Outstanding Balance Due:
,S 51N T I Z—I
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 6qd q 05
;�
O&'c-Q C,�-C,'. License Number Expiration Date
N;a e of CSL Holder List CSL Type(see below)
Type � Description
No.; ud Street
y ti M C, O U RUnresestri rictcxl� Duildin s u el 35,000 cu. IlJ
C)n 1 I �g R ResUicteJ I&2 Fumil Dwellin
Cityll'uwn,State,LI ibt Ninsonry
RC Rooting Covering
WS Window and Siding
l 'I SF Solid Fuel fuming Appliances
p ✓� 02� `I t Insulation
'Tole hone Email address U Demolition
5.2 Registered Home Improvement Contractor(HIC) ) / 3a 3 l) /5/
HIC Registration Number Expiration Date
HIC Company Name or 111C Registrant,�1u7
1., i S A J16q(
T.odnd:oZ a9a Email address
City/Town,State ZIP Telephone
SECTION 6:WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 15L§ 2SC(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:TOBE COMPLETED WHEN.
"
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT'
r
1,as Owner of the subject property,hereby authorize w\ C M
t9 act on my behalf,in all matters relative to work authorized by this building pepitit application.
N
Print Owner's N;mie(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 thus application is true and/accurate to the best of any y knowledge and understanding. y/
Print Owner's or Authori Agent'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 Flome Improvement Contractor(HIC) Program),will nol have access to the arbitration
program or guaranty fund under��LG.L.c. 142A.Other important information on the HIC Program can be found at
"I'llmes. o s �sv'oca Information on the Construction Supervisor License can be round at www.nvisir ov-!dL .
2. When substantial work is planned,provide the information below:
'total Moor area(sq. 11.) `� .(including garage, finished basementlatlics,decks or porch)
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 for"'roGd Project Cost"