30 FOREST ST - BUILDING INSPECTION t1
The Commonwealth of Massachusetts, SPECTIDNAL SE VY OF
Board of Building Regulations and Standaar IC�.I.
-
Massachusetts State Building Code, 780 CMR SALEM
20
2:2
ate
e dMar2011�b �AR A ��
Building Permit Application To Construct,Repair,Renov r emolish a
One-or Two-Family Dwelling
This Section For Official Use Only
N Building Permit Number: Date Applied:
I 3ZZ I(o
9 Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
I
1 Pr e dress: 1.2 Assessors Ma &Parcel Numbers
D�4�. 4 5alew m p
L l a 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 11) Frontage(H)
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 OWNERSHIP'
2.1 Owne of Tcordy
/(aKgr 6L 17T—l
NNa ne nnt) t City,State,ZIP
No.and-Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work : 1p
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 300 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (IIVAC) $ List:
5.Mechanical (Fire Suppression)
$ Total All Fees:$
3 Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ pD 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 53 vL
"'�r—,4"Q - ' License Number 9xpiration Date
N e of CSL Hol � I
3��� E5k /J��/�__� ,�/J/t List CSL Type(see below)
No.and Street' �y—��j)/ ,/off Type Description
M_ � 4/4 ��/ U Unrestricted(Buildings a to 35,000 cu.ft.
�r1�t`7 �Y R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
2s(5��/ 5, 060, CVCO ""rl" SF Solid Fuel Burning Appliances
I Insulation
Telephone i Email address D Demolition
5.2 RegisteredRo�m�e/yII pr/oXeeme tContt ctor(RIC) /r15�/iiD109
r°�~"t� "�"' JWCTRegistraattiion Number Expiration ate
?fHCCo
y yI`GGG1II/G , .
No.and tree ,p t1/['C f CGiO Email addres
City/Town,State,ZH' f, J� Telephone J
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 ..........Iff 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 b half,in all matters relative to work authorized by this building permit application.
Print ner's Name lectronic 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. A
int 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
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass. og v/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"may be substituted for"Total Project Cost"
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