15 HARRIS ST - BPA - B-16-623 a
The Commonwealth of Massachusetts }
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Board of Building Regulations and Sta4&0p C. 1
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Massachusetts State Building Code, 780 CMR SALEM
� Wvised Mar 2011
���Building Permit Application To Construct, Repair, Reno&lbe ollssPt as
One- or Two-Family Dwelling
^ 1 This Section For Official Use Only
lnnv Building Permit Number: Date A ied:
(i at!iyys� /Y
�y Building Official(Print Name) Signature Daee
SECTION 1: SITE INFORMATION
1.1 Pro erty Address: 1.2 Assessors Map& Parcel Numbers
i l�l4 y eAdd S-f-
1.1 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(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:
(—'Igo k L42f Abr e— .SJe m YhA 01 i 7 0
Name(Print)I City, State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) PJ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
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SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost' (Item 6)x multiplier _;�—x—7-
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: $ IDS ❑ Paid in Full ❑Outstanding Balance Due:
(Yl (a I �Y] ZA-O C7 C, (c
SECTION 5: CONSTRUCTION SERVICES
5.1 Constr^Cuction•SYup rvtsoL.ticehse.(CSL) ^ `
rf i�J n he t-- Zo License Number Expiration D to
Name of CSL FIbloer K� t
digs List CSL Type(see below) (�
CIS pf
No.and Street �t Type Description
� � n/I AL /� �l U Unrestricted(Buildings u to 35.000 cu.ft.)
" 1 ! V R Restricted 1&2 Family Dwelling
City/Tow , ta�P M Masonry
_ RC Roofing Covering
WS Window and Siding
�7 SF Solid Fuel Burning Appliances
/ _ �qi-o yay I Insulation
Telephone Email address D Demolition
5.2 Regii�stered Home Improvement Contractor(HIC) O/ �On
r n A � r U Le� HIC/Registration%Number piraCon a[e
HIC C mpa Name or HIC Re i trant Name
No. S eet Email address
- - e w, ki l A- ()J S 0 g ?� 7�{/' �i}0
City/Town, ,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
1,as Owner of the subject property,hereby authorize LQ&S
to act on my behalf, in all matters relative to work authorized by this building permit application.
CpVoL L14212 ,46te- 9 h
Print Owner's Name(Electronic Signature) I Dat
SECTION 7b: OWNERS 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.
Print Owner's or Atithorized Agent's Name(Efectronic Signature) D to
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. og v/oca Information on the Construction Supervisor License can be found at www.mass.eov/des
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"