10 GABLES CIR - BUILDING PERMIT APP / The Commonwealth of Massachusetts
i Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 C MR, T°edition f3F SALEM
�llrrrZZZ Revised Junuury
Building Permit Application To Construct, Rep ' , Renovate Or Demolish a /. ?008
or Two-Family elling
is Section F fTtciai Use Only
Building Permit Number: Date Applied: l
Signature: �/.7��. d
Building Commis r/ It Buildings Date r�
TION 1:SITE INFORMATION
1.1 Propert dress: 1.2 Assessors Map& Parcel Numbers
/1-S 0
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 B) Frontage(tl)
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:
Zone: _ Outside Flood Zone?Public O Private❑ Check if es❑ Municipal[3 On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
.1 Ownert of Record•
�ciwr4S �- �eW vesS�z
e(Print) Address for Service:
'77K 7yY85-lG
tgna re Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied [3Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. [3 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how tee is determined:
2. Electrical S ❑Standard Cityrrown Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IfVAC) $ List:
5. Mechanical (Fire S1127
Su ression Total All Fees: S
Check No. Check Amount: Cash Amount:
b. Total Project Cost: S - �• ❑Paid in Full O Outstanding Balance Due:
SEA o� P474442 /*TT64 A/tnnot su2✓'`�
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Con tructlon Supervisor(CSL) 16 LQ jn
t.icense Number Erp' tian I ute
N�e1 C — l�� Cp.�- [Ast CSL Type(see below)
(( �` Uescri Lion
Address D Unrestricted a to 33,DOO Cu.Ft.
i�--� R Restricted I&2 FamilyDwellinit
Signawrc M Mason Onl
RC Residential Routin Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
n1h3te ImTprovem m ontra r r(HI ) l �R�6
�M--4 Registration Number
f2(a Registraptk1 ,0 i (76�/ Expiration Date
Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.¢ 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...........13
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 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.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1 as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name �T)
Signature of Owner or Authorized Agent " Date
(Signed under the pains 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 WJ have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"