10 HAZEL ST - BPA-14-1161 ^oo
Sa The Commonwealth of Massachusetts
"t Board of Building Regulations and Standards CITY OF
� ! Massachusetts State Building Code, 780 CMR SALEM
Revisec(Mnr 20/l
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fornily Dwelling
This Section For Official Use Only
Building Permit Number: Date died: — —7
Building Offimal(Print Name) Signature Date
SECTION I:SITE INFORMATION
1.1 Property Address: 1.2 Assessors iYlap yr Parcel Numbers
L la Is this an accepted street?yes__ no Map Number Parcel Nurn ber
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq Pt) Frontage(n)
1.5 Building Sethacks(ft)
Front Yard Side Y:uds (tear Yard
Required PmvideJ Required Provided RcquireJ Provided
1.6 Wafer Supply:(NLG.L c. 00.§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 Ownerr of Record:
tar dyn ADanp
Namc(Print) (` City,Stale,ZIP
No.—Street "telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 .Accessory Bldg. [I I Number of Units__ I Other ❑ Specitq: _
Brief scnjTtion of Proposed Work/,�
SECTION 4: ESThNUtTF.D CONSTRUCTION COSTS
Item Estimated Costs:
labor and iMalerials Official Use Only
I. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City1rown Application Fee
❑Total Project Cost(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $ _
d. Mechanical (I IVAC) $ List: _
i. Mechanical (Fire
Su t ression) $ Total All Fees: $
Check No. Check Amount: _Cash Amount:
6. 'Ibfal Project Cost: $ ��a ❑ Paid in Full ❑Outstanding Balance Due:
r87 r � Z� 7/ 7 �
1 1
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supe"isorrr License(CSL) ML/ 72 / 1//
License Number Expiration Date
Name of[CSL Holder
List CSL Type(see below)
1,016?r e
No.and Street r / Type Description
U Unrestricted Buildin s up to 35,000 cu. ft.
.l r / iii ✓ ✓ Restricted I&2 Tamil ITvelling
Gtyaown,State,ZIP
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) ^ ?-5
S"
IK
IiICCompanyNimeorHICRegistrant Name
C Registration Number Expiraton Date
No a e G // Ace
�11f_,i1 Email address
Ci[ /'rown,State � h
,ZIP Cll 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 pennit.
Signed Affidavit Attached? Yes .......... ❑ No...........O
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 relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) 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 't his a lica =theis best of my knowledge and understanding.
Printrint OwneAgent's Name(Electronic Signature) 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 I.G.L.c. 1 d2A.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.mass.gov/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq. RJ _(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"
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