75 FLINT ST - BUILDING INSPECTION (2) iR r
fhe Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Cole, 780 C'MR, 7'edition OFSALEM
Rewisr/Jo.ra.wc
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I)utlJtn8 Permit Application To Construct, Repair, Renovate Or Demolish a
�t One-or Two-ForrrilY Dwelling
This Section For Official Use Only
Y1 Building Permit Number: Date Applied:
Signature:
Huilding Commissioner/Inspector of uil ings fate
USECTION 1: SITE INFORMATION
1.1 Property Addr 1.2 Assessors Map& Parcel Numbers
I.la Is this an accepted street?yes no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Am(sq 11) Frontage(11)
1.3 Building Setbacks(it)
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 Sewap Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHIP' /7
2.t Own S AYI1,00 i14L4 J 1/) I �In--
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check)Vd that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ff I Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011lelal Use Only
labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard Cityfrown Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
J. Plumbing Is 2. Other Fees: SS
4. Mechanical (IIVAC) S List: (i(J
5. Mechanical (Fire S
Su ression Total All Fees:S
Check No._Check Amount: Cash Amount:
6. Total Project Cost: S ❑Paid in Full 0 Outstanding Balance Due:
- 1
SECTIONS: CONSTRUCTION SERVICES
5.1 Llcesse astructlon M&uT
sor(CSL) Q(,t),An
I.icense NLLu4miscl, F%ptra on Me
Name o • I to r list CSL-type(see below) l )�
f Dmripoion
:WJ U I Unrestricted(up to 35.000 Cu.Ft.
R I Restricted Id2 Family Dwelling
Sianutu ram^ M I Masonry only
RC Residential Rooting Covering
I'clepMms WS I Residential Window and Siding
SF Residential Solid Fuel Burning A fiance Installation
D Raidrntiol Demolition
!.I Registered Ho m re e f Co 0 NIC �
IIIC Co IIIC Registrant Registration
of c�
Ad t!DSrrdh� P
Es iration u
Si '(clephune
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.IL e. Ill. I ISC(6))
Workers Compensation Insurance affidavit must be mpleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the IssuVee of the building permit.
Signed Affidavit Attached? Yes ..........6 No...........O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRA OR APPLIES FOR BUILDING PERMIT
I -D, da IT 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.
SismatureotOwner Dote
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
RWF1 ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are We and accurate,to the best of my knowledge and
behalf. F O
Print
L]
Signature of(7tvnc#or Authorized Agent Date
Si under t ains and penalties of 'u
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 do have access to the arbitration
program or guaranty fund under M.G.L.c. 1.12A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations 110.R6 and I IO.R3,respectively.
2. When substantial work is planned,provide the information below:
Total floors area ISq. Ft.) (including garage,finished basement/attics.decks or porch)
Gross living area(Sq.Ft.) Habitable room count
Number of ftrep►aces Number of bedrooms
Number of bathrooms Number of half/baths
Type of healing system Number of decks/porches
Type of cooling system Enclosed Open
). "Total Project Square Footage"may be substituted for"Total Project Cast"