5 HARMONY ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date A plied:
55
Building Official( riot Name Signal a e
SECTION 1: SITE INFORMATION
1.1 Pro erty Address: 1.2 Assessors Map At Parcel Numbers
5 r S .
Lla Is this an accepte street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq fi) Frontage(11)
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 Record•
` avr Ka 619 -1
Name(Print) City.State,ZIP q
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction El Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other El Specify:
Brief Description of proposed Work2: ( .
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ f' / 1. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cos[ (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire Suppression) $ Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ( g Q(p. 11 Paid in Full 0 Outstanding Balance Due:
' r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 0-![7 3 ����`�
r!"S 20 0 - License Number Expiration Date
Name of CSL Holder LA
^'O i List CSL Type(see below)
No.and Street
Type Description
Ma O 19
7 0 U Unrestricted Buildin s up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
2`�gi?�'�—6� I Insulation
Tee hone Email address D Demolition
l
5.2 Registered Home Improvement Contractor(HIC)
Q 1 D I �o o`� (O"�-�
&-+ }[— ✓r Z-Q_S H C HIC Registration Number Expiration Date
HIC Company rN�am i tran
'e or HIC Regs Name
No. d St eet CM
address
oi�-e Y� 11� 0 L l t 0
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 K h✓t"Si TV,-?
to act on my behalf,in all matters relative to work authorized by this building permit application.
gtTaLk,.P_,- CUro'-CGIC." - <g /
Print Owner's Name(Electronic 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
contai in this application is true and accurate to the best of my knowledge and understanding.
t-Print Owner's or Autho ed Agent's Name(Electronic Signature) ate
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
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
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'