81 FLINT ST - BUILDING INSPECTION (2) G3� 12,3 ij
ga The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
WMassachusetts State Building Code,780 CMR SALEM
'Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Numbei: Date Applied:
r Building Official(Print Name) -Signature ' Date tc'
vv`7nll SECTION I:SITE INFORMATION
1 1.1 Property dress: 1.2 Assessors Map&Parcel Numbers
�9 i 'i, J k s� 'F rr t
i Lin Is this an accepted street?yes no Map Number Parcel Number -
�ci
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(R) a
1.5 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 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION?: PROPERTY U&WNERSIDPt
2.1 Owner'of Record:
�Q�r✓k LciAh% , o czv. InS 02iY1
Name(Print) City,State,ZIP
yaz ti5d-( A-v, #Svc &0 --25-7 9"
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(oheelr all that apply)
New Construction❑ 1 Existing Building Erl Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ErrAccessory Bldg.❑ 1 Number of Units Other ❑ Specify:
Brief Description ogp ProposedWork : �.vv` c yC ,D I J S 0 (-nmac LoW-At K. M'F^'+%
W vT11f d+2 20 2sin�Ltc ilczalc 'Q
A/♦F (CG+Z.' d
SECTION 4:ESTIMATED CONSTR TION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ j U o0 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ 5 00 ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ -Zc,a o 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire Supression) $ Total All Fees:$ -
Cheek No. Check Amount: Cash Amount:
6.Total Project Cost: $ t)v G ❑Paid in Full ❑Outstanding Balance Due:
i
P/ � �yf 91%
ors i� 4 P.l'u t, 2-2—
SECTIONS: COINSTRUCTIQA SERVICE
5.1 Construction Supervisor License(CSL) /(] / / tl/ - 2�5'. 17
n
t` '�A (2a J•2 tCe, License Number Expiration Date
Name of CSL HiAder
List CSL Type(see below)
No.and Street
T Descaiption
l\2 cU L D / U Unrestricted uildin s u to 35,000 cu.ft.
7 Restricted 1&2 Family Dwelling
-Cityrown,State,ZIP M I Masonry
4• - RC Ro fing Covering
_ WS Window and Siding
SF Solid Fuel Burning Appliances
;r9-7g 796y,y� I Insulation
`Telephone Email address D Demolition
r 5.2 Registered Home Improvement Contractor(IHC) ' -� !J 711
aov 24-1- ya.d(f,, „ ✓ r/r^c vi,� HIC Registration Number Expiration Date
'HIC Company Name or HIC Re strain b2ime
I S-ri P/t21_J x-a A-Ic
No.a1dStr
G I 1 D 97� f4 I /L/,.1 Email address
City/Town,State ZIP 7 oTel /hhone
SECTION 6:WORKERS°COMPENSATION INSURANCE AFMAVIT(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........... ❑
SEC'I'ION'ia:'OWNER AUTHORIZATION TO BE COMPLETER WHEiv
OWNER'S AGVNT OR CONTRACTOR APPLIESP4R BUH,DING PERMrr
1,as Owner of the subject property,hereby authorize /yvt 02,E, 3 24LLc'
to act on my behalf,in all matters relative to work authorized gy this building permit application.
C '
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 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
wlvw.mus.Qov./oca Information on the Construction Supervisor License can be found at taww.mass. ovg /dos
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"maybe substituted for"Total Project Cost" ' 4