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9 1-2 INTERVALE RD - BPA-16-1270 . e. The Commonwealth o1't ``rats CITY OF Board of Building Regulations and Standards SALENI Massachusetts State Builgf(f ,280CPJR2: 02 Revised,Liar20/I 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.Applied: \�\ Building Official(Print Name) Signature ( ate SECTION ii SITE INFORb1ATIOW L 1 Property Address: 1.2 Assessors NMI;& Parcel Numbers 9r/2 IIV I-CyVALt �{� yaleM MA 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(sy 11) Frontage(11) 1.5 Building Setbacks(it) 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: Zone: _ Outside Flood Zone? Municipal O On site disposal system ClPublic❑ Private❑ Check if es❑ p SECTION2: PROPERTY OWN ERSHIP!` 2.1 Owner of Record: LVIVA1 t 0/9 02 �me(Print) City,State,ZIP �O,iro � lfane.� o� 61}g23 ©8q2- -3o,ervava@.:M11aiL-fj No.and Strect T2 Se.t' C te,Y •f Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Altemtion(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ rN Other D Specify: Brief Description of Proposed Work': " (Pei tMa 0,1--- d1 to . RX Chf. Gw (&30. WA L -�:hoof (AS MOy141 a eharlap 3 Boors 4n�911f ` cl em 0 a SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Nlateriais) I. Building 1. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical Slgaa - ❑Total Project Cose them 6)xmultiplier x 3. Plumbing S i 8CA 2. Other Fees: S 1.Nlcchmrical (FIVAC) S List: y�1 5. Mechanical (Fire S Total All Fees:S Suppression) Check No._Check Amount: Cash Amount:_ 6. Total Project Cost: S Cl Paid in Full ❑Outstanding Balance Due: ry) CQ'1L�7J tul� 1 SECTIONS: CONSTRUCTION SERVICES 3.1 Construction Supervisor Liccnse(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) Type - Description . Nu. ;uid Street U Unrcslricted Duildin s tip to 35,000 cu. tl. R Restricted 1&2 Family Dwelling City/rows,State,ZIP ., M Masonry RC Rooting Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation -Telephone- Email address D Demolition 3.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.mid Street Email address Cityfrown,State ZIP Tele hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 15L$ 2SC(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 Isivance of the building permit. Signed Affidavit Attached? Yes ..........❑ No........... 13 SECTION 7a:OWNER AUTHORIZATION:TO BE COMPLETED WHEN.. OWNER'S AGENT OR CONTRA&ORAPPLIES`FOR BUILDING.PERMIT' 1,as Owner of the subject property,hereby authorize t9 act on my behalf,in all matters relative to work authorized by this building permit application. XPrint Owner's Name(Electronic Signature) Dale 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 in this application is true and accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Nmne(Electronic Signature) Date NOTES: I. An Owner who obtains a building permit to do his/her own+vork,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. 1 d2A.Other important information on the HIC Program can be found at ww+v ntas;eov'oca Information on the Construction Supervisor License can be found at wt+w-.muss.��o+�'Jns 2. When substantial work is planned,provide the information below: Total floor area(sq. ft.) (including garage,finished basementlattics,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"rutal Project Cost" c