3 FILLMORE - BUILDING INSPECTION 1
" I�l b c � 10%5
The Commonwealth of Massachusetts"
Board of Building Regulations and St� RECEIVED CITY OF
Massachusetts State Building Code, 7$0'C rIGNAL SERVIC `S SALEM
7 uwu Revised Mar 2011
Building Pemtit Application To Construct,Repair,Re a r mQ6is
One-or Two-Family Dwelling
This Section For Official Use Only., III
3/ Building Permit Number: Date pplied.
Building O$ieiat(Print Name) Signature
SECTION 1: SITE INFORMATION
�j 1.1 Pro Ad
1.2 erty Assessors Map&Parcel Numbers
/ j Y1l�rL
I.la 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(it)
) Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
7
1.6 Water Supply: (M.G.L c.40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: -Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal ElOn site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP`
2 1vn a of Re ord: A
re(Print City,S te, IP 61 l
No.and Street �— Telephone Email Address -
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction-❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1..Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ •� y� 1
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $/dt POP Check
Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Constru on Supervisor '• se(CSL) L•J 7/lj p 0 C
h � �7 717
/�
I•/ IR a lot)l A!da License Number Expiration D to
;i Name of CSL flolder
Wn List CSL Type(see below)
No.an trees Type Description
Weel , pa�55 U Unrestricted(Buildings up to 35,000 cu.ft.
e ty/ t vy,State,ZIP R Restricted 1&2 FamilyDwelling
M Masonry
RC Roofing Covering
WS Window and Siding SF Solid Burning Appliances
thor)si��-DN D I insulation
Telephone Email address .-evol Demolition
5.2} y
R�egtister/W Home Improov cut Contractor(HIC) /a Is a
/V' 1 fk On S- X 'o R1 HIC Registration Number Exptrati a Da[e
H C Comp Name or HIC ReB rs trant N e
No Stre t m SI�V y�'nepnsfniea,6
� u �
n�i9bJ
/ - pk Email address
Ci / own, 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) Dare
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 is application is and accurate to the best of my knowledge and understanding.
1,/lc m MMI
Prnt weer s or Authorized Agent' m lectronic Signature) Date
NOTES:
1. An Owner who obtains a building per_^tit 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 nass.,ov/oca Information on the Construction Supervisor License can be found at www.mass.eovidns
2. When substantial work is planned,proQp 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"