26 GABLES CIR - BUILDING PERMIT APP (002) s idk AA
S The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
R�C�IVE RevisedMar2011
Building Permit Application To Construct,Repair,�p EM rkL SIC $
One,or Two-Family Dwelling
This Section For Official Us ly
Building Permit Number: Date Apple :
Building Official(Print Name) _ ' Signature Date
SECTION 1:SITE INFORMATION
1.1 Proper dress: 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?ye 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(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 Owner'of Reco inn C 1� JF� Q 1� � lq 7
Name(Print) City,State,ZIP
a6 G� b ��� c;� quo -?qy - ggy�C,
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply) -
New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ 1 Repairs( Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
BriefDescriptio Proposed Work:
t vt a Ld
SECTION 4:ESTIMATED CONSTRUCTION COSTS.
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 8 — "1. Building Permit Fee:$ : Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
. umbing $ 2. Other Fees: $
4 M /r7rl
.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression -Total All Fees:$
6.Total Project Cost: $ Check No. Check Amount Cash Amount:
( ❑Paid in Full ❑Outstanding Balance Due:
i
SECTION 5: CONSTRUCTION SERVICES
5.1 F'eJ�tstru1_ction Supervisor License1(CSL) 6 6� 1 b 9p
)7,b pJ" - �bc-7 &b d- " License Number / Expiration Date
NamIof CSL Holder I
Y/1LJ Lis[CSL Type(see below)
No.and Street Type I Description
S>C�12- M I Q U Unrestricted(Buildings u to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
r _ SF Solid Fuel Bunting Appliances
W - Z I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) / 2 { q 3 W -3 -4
l4;IMC De
HIC Registration Number Expiration Date
HIC otnp�y N .o6FK(?,egi ram Naptj ^
UU CC�� JJ NN -rL r iJ
NoT4*tt �Vor ' Email address
City/Town,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.
Sl L c3h4�-aI )J '61 - q - ���
Print Owner's Name(Electronic Signature) Date
SECTION 76: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. (l
MatrlC IV u bh rn L� s �n � O �l - (L✓"
Print Owner's or Authorized ent's N (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
xitivw.mass. ovoca Information on the Construction Supervisor License can be found at www.niass.govt /dns
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"