10 INTERVALE - BUILDING INSPECTION 00
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The Commonwealth of Massachusetts
WBoard of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Building Permit Application To Construct,Repair, Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only - -
Building Permit Number: Date Appli
- Bmldmg Official(Print Name) Si atu -
� ate
SECTION if SITE INF
1.1 Properly Address: 1.2 Assessors Map&Parcel Numbers
I.Ia Is this an accepted street?yes no Map Number Parcel Number ..
13 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?
Check if yes[] Municipal❑ On site disposal system ❑
SECTION 2:PROPERTY OWNERSHIP'
2.1 Owger'of Record: 6 /
Name(Print)
City,State,ZIP
In -n 7k4()u.(,C—
No.and Street Telephone P Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction ❑ 1 Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1Accessory Bldg.❑ Number of Units ( Other ❑ Specify:
Brief Description of Proposed Work : 191
G1ooI1 Ce ��ulw� e �lC(IS 2 - (S t
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Only
Labor and Materials y
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ El Standard City TowmApplication Fee
❑Total Project Cost'(Item6)x multiplier - ,x- -
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Su ression) $ Total All Fees:$
6.Total Project Cost: $ a OQ OD Check No. Check Amount: Cash Amount:
1 ❑Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
3 Hilton Street List CSL Type(see below) vt
No.and Street Type Description
U Unrestricted(Buildin s u to 35,000 cu.ft.
City/I'own,State,ZIP Restricted 1&2 Famil Dwellin
M Maso
RC Roofm Coverin
WS Window andSidin
SF Solid Fuel Burning Appliances
1 insulation
Tel one Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant a HIC Registration Number Expiration Date
I Jeffiftm Avenues T P0.1/4 01 Q CC . vc�
No.and Street Salim MA 01970 Email address
Cr !Town,State,ZIP Tele hone
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 f 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_
to act on my behalf,in all matters relative to work authorized by this building permit application.
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Print Owner's Name(Electronic gnature) 14 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
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in this applicatioon�is true and accurate to the best of my knowledge and understanding.
Print Owners or Authorized Agent's Name(Electronic Signature) ( Date
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 Lnprovement Contractor(HIC)Program),will no!havea ccess to the arbitration
program or guaranty fund under M.G.L.c. I42A.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 govldos
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"maybe substituted for"Total Project Cost"
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