14-20 INDIAN HILL LN - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7h edition OFSALEM
RevisedJanuary
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
This Section For OfficiaFlUsd-Only,
Building Permit Ndffijb�n
Si _40,
'Building Comniissimieitlnspe Ing
6torofBuil,d' a Date;
SECTION!-SiTVINFOIWATION: _
1.1 Prop 1.2 Assessors Map& Parcel Numbers
U4 Property
M11 LsMe__ 3 006(�
L]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(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 0 Private El Zone: Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yesO
SECTION 2:::PROP
ERTY OWNERSHIP
2.1 Ownerl of Record:
0 Hlei"d Ave Name( .c
for SeY�ice:
7_� 200->,
-Signature i2pyhone
r
SECTION.3- DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) III/ Alteration(s) 13 Addition 0
Demolition 0 Accessory Bldg. C1 Number of Units I Other 0 Speci
Brief Description of Proposed Work : 'ST c i CAci kr.--)- ' o,rA ii\ s,�,kk
SECTION:4i ESTIMATED r CONSTRUCTION 1 COSTS
S
Item Estimated Costs: Official Use Only
)(Labor and Materials
I. Building $ l:- BuildingPermitFee-$r rr Indicatehow fed is determined:
, W
2. Electrical $ 0 Standard City/Town'ApDlidiation Fee
0 Total q Project,Cost (Item r In r Iiltipliei..
,9 r .5' ' 9 X
�',6tberPees:
3. Plumbing $ r. --4. Mechanical (HVAC) $ List:
5. Mechan
ical (Fire
So ression $ Total All Fees�
6. Total Project Cost: $ b c CheckAmount: Cash Amount:
l
Check No.?5 tj Piad.in.Full EI Out'stan
,❑I .dihgrBalance Due:
SECTION 5: CONSTRUCT[ON'SERVICES
5.1 Licensed Construction Supervisor(CSL)
T nn GS SL �Cz iD�� 12- �4 - II
,rj 1Gy`f05 /r 1D0t.SOy/e. , License Number Expiration Date
Name of CSL-Holder _
// WdsCJn - 5 Sc�p m{, List CSL Type(see below)
Address 'T ° Des&i tion•
U Unrestricted ((up to 35,000 Cu.Ft.
Signature R Restricted 1&2 FamilyDwelling
Signature �� M Mason Only
fJ97 RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor
C /�✓� r�ar , P C A 'er, CO(HI InC C)
1514326
HICe Registrant Name Registration Number
l ) L1%i/SCn sT y < to Mj� t71G70
Address �9 -27 - /I
cy
` Y- 7 -ss 70 Expiration Date
Signature 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 LBU,
ILDING PERMIT
I. 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.
Si nature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION , .,
I> A Lirl L ���one�Ti CPS as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf
s ouJsnt�
Print Name
u f wn r Authorized Agent Date
(Si ne a ains and enalties of er'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 of
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I IO.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"