0013D GRISWOLD DRIVE - BPA-13-321 ow U The Commonwealth of Massachusetts CITY OF
Q Board of Building Regulations and Standards
Vt,/ Massachusetts State Building Code, 780 CMR SALEM
Revised.War 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
\ One- or Two-Family Dwelling
1/
This Section For Official Use Only
n Building Permit Number: Date Applied:
dA1 �
l
Building Official(Print Name) Signature Date
SECTION l: SITE INFO MATION
1.1 Property Address:?, GfiSwol J Df 1.2 Assessors Map& Parcel Numbers
�
I.I 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 ft) Frontage(ft)
1.5 Building Setbacks(ff)
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?
Check if ves❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Rec rd•
11 70
rty,
Name(Print) C State,ZIP 7
6.654, Df �17` �6Y—o6a14
a
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) N41 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other 16 Specify:
Brief Description of Proposed Work':
IP(i t /pj /b AG �u
��
SECTION 4: ESTIMATED CONSTRUCTION dOSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 16(3 37 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 $ i 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire
Su ression) $ Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 3,3�
6 ❑ Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
_ w 187 b' i3
Rt, LI.St? f1 License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
tan Street Tye Descri tion
No.gan�d Street YP P
U Unrestricted(Buildings up to 35,000 cu.f.)
Cih/To / R Restricted 1&2 FamilyDwelling
Stale, IP M Mason
-Z RC Roofing Coverin
iry
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) L
Lowe1
I1IC Registr lion ember expiration Date
HIC Company Name 9rHIC�y istrant Name
l3� 'tLfnvtfZc F -
No. and S r-e m s
rout A 1n.4 p 177A Z/7-3rf-,7?,qC
City/Town, State,&P '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
1, as Owner of the subject property, hereby authorize
to act on my behalf, in all matters relativ to work authorized by this building permit application.
�rtore,_l�rrwis I ►m 4��5
Print Owner's Name(Electron e ignature) Date
SECTION 7b: OWNEW 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 a d ac rate to the est of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(ElectronicSignature) Date
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 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.ntass.sov/dps
2. When substantial wort: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"