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12 HANCOCK ST - BPA 'w The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEM, a Revised:IAur_0/l ^ , C'�I( Building Permit Application T onstru-t. Repair. Renovate Or Demolish a !Ix-or- Two-Pert lly Dwellinq This Sect or Official Use Only Building Permi ,'umber: Date A Building Official(Print Na te) V` Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map d Parcel Numbers l2. aAn�oc-lC s-r I.la Is this an accepted street'yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: %oning District Proposed Use Lot Area(sq f1) Frontage(f1) 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: Zone: _ Outside Flood"Lone? Municipal❑ On site disposal s�•stem ❑ Public ❑ Private❑ Check if ves❑ p p SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Name(Pruitt City..State.ZIP )2 ykck,n co?-581-14U3 No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction Cl �Existin�g�Buildmg:e' ner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessorber of Units_. Other ❑ Specify: pV So f Brief Description of Proposed Work': U S a (L SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) I. Building S 1. Buildine Permit Fee: S Indicate how fee is determined: ❑ Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost'(Item 6)s multiplier s 3.Plumbing S 2. Other Fees: S 4.Mechanical (HVAC) S List: 5.Mechanical (Fire S Total All Fees: S Suppression) Check No. Check Amount: Cash Amount: 6.Total Project Cost: S Lk R, 5SO.°' 0 Paid in Full ❑Outstanding- Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction SSuupervisor License(CSL) S'7328 tyy_/ �©�� 5 / 3Z8 License Number Expiration Date Name o>'CSIIfolder List CSL Type(see below) k JJ, Description No.and Street /V6 ("� _/�G/ /]� d� U Restrictet 1&2Fldii(Buildings up toiniz cu.ft.) .J /`� K- 7� R Restricted I&?Pmnil_r DNcelling Citvflown.State.ZIP A9 Nlasonrr C 10A, Q f Af/ RC Roofing Covering WS Window and Siding p '/ f / A /,,, SF Solid Fuel Burning Appliances ?0,6!/r Y�Q rJi/f��!" ^�""M I Insulation "felt hone Email address D Demolition q t 5.2 RegistereomelmprovemgenntConftractor(HIC) /Z6133 Zm�Z /J � U 141C{�y! / �/` /1 HIC Registration Number Expiration Date Ii1C Con'p� ` ^ne�f�N.rCeelv�`lam�l V J.�.rl�Pv& e— CO'Irl�t'�./J�� // G /'—O No.and Street �;y VUO Email address eA/1L�SGE M.�j 7 City/Town. State.ZIP zle hone SECTION 6: WORKERS'COMPEiNSATION 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�he building permit. Sieved Affidavit Attached? Yes .......... No........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT L bject property,hereby authorize ✓n all matters relative to work authorized by this building permit application. P/3-if 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 li containedlyrtRis application is true and accurate to the best of my knowledge and understanding. '11��Ils for P e s or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do hislher 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. 1 d2A.Other important information on the HIC Program can be found at wwly mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos 2. When substantial work is planned, provide the infonnation below: Total floor area(sq.ft.) (including garage, finished basement/anics.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 ;. "Total Project Square Footage"may be substituted for"Total Project Cost"