23 HANCOCK ST - BPA (003) k
J
The Commonwealth 01'Mas52chusetts
(J Board of Building Regulations and Standards CITY
.r Massachusetts State Building Cute, 780 C'MR, 7e,edition OF SALEM
Rrvisrr/Junnrvr
Building Permit Application To Construct, Repair, Renovate Or Demolish a /. :rRtiY
one-or rwo-Family Dwelling
This Sectio ORcial Use O
Building Permit Num r: ate pp '
Signature:
Building Commissioner/In tar t
f Buildin Date
qnMoofk SITE INFORMATION
1.1 Properly Address: 1.2 Assessors Map& Parcel Numbers
3 J-l9rvCucK S� ASH 7Fr� 7'? �
I.1a Is this an accepted street?yes no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Arm(sq 11) Frontage(it)
1.5 Building Setbacks(ft)
From Yard Side Yards Rear Yard
Requ(ml Provided Required Provided Requiscd Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public O Private O Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Cheek if es0
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownert of Record:
'7—f)nGS �Oil^�SUyI/ 023 f/yNCuGK 5 ,4
Nome(Print) Address for Service:
r Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(check aU that apply)
New Construction 0 Existing Building O Owner-Occupied O Repairs(s) O Alteration(s) O Addition a
Demolition O Accessory Bid- rl Number ofUnis_ Other O Specify:
Brief Description of Proposed Work': ke On Ffrnva ,S:l.�s 4` c%t
SECTION 4: ESTIMATED CONSTRUCTION COSTS
16Total
Estimated Costs: Of elal Use Only
Labor and Materials
ng S I. Building Permit Fee: s Indicate how fee is determined:
cal S O Standard City/Town Application Fee
O Total Project Cost(Item 6)x multiplier x
J. ing S 2. Other Fen: S
nical (HVAC) s List:
nical (Fire s
an Total All Fees: s
Check No. _Check Amount: Cash Amount:
Project Cost: S /(J0U-Jo 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
fRegillored
Construction Supervisor(CSL)
JR
e Number Expiration oats
(At.- lulder SL Type Ixe below/
Dewri ion
Address Unrestricted u to 15.0W Cu.Ft.
Restricted 1A2 FamilyDwelling
M Only
Residential RoutingCovering
Residential Window and Siding
Residential Solid Fuel Burning Appliance Installation
Residential Demolition
Home Improvement Contractor(HIC)
I IIC Company Name or HIC Registrant Name Registration Number
Address Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. IS].f 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.
tau,tPhonin
avit Attached? Yes ..........O No...........O
a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
to act on my behalf,in all martenork authorized by this building permit application.
w Date
SECTION 71b:OWNER'OR AUTHORIZED AGENT DECLARATION
l ( ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are We and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of owner or Authorized Agent Dale
iSimnedunder the psins and penalties of 'u
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 W have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations 1 I O.R6 and I MRS.respectively.
2. When substantial work is planned,provide the information below:
Total floors area ISq.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 are
Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
). 'Total Project Syuarc Footage"may he substituted tor"Total Project Cost"