320 JEFFERSON AVE - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
rj( � Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two Family Dwelling
This Sectton,For'Official Use Only
Building Permit Number. 'Date Ap lied>`.
1 7kaxsd
Building Official(Print Name) Date
SECTION 1: SITEIPIF TION
4.1 Property Address: 1.2 Assessor ap & Parcel Numbers
y �cLJ. ran Aue
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.O.L c.40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Municipal if yes❑ unicipal❑ On site disposal system ❑
SECTION 2 PROPERTY'OWNERSHIPI°
2.1 Ownert of Record:
r S4 V\_19361N Sc,.lcyv\ � V\A ®t 319 70
ame(Print) 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) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description f Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS.
Item Estimated Costs: Official Use Onl
Labor and Materials y-,
1. Building $ L Building Permit.Fee S Indicate how fee is determined:
2. Electrical S ❑ Standard.City/Town Application Fee
❑Total Project Cosf,(Item.6)x multiplier x
3. Plumbing S 2 Other Fees: S
4. L
c, (HV:\C) S List.
cal (FireSun) Total All Fees: S
Check No. Check Amount: Cash Amotmt:
6 'Ibtnl 1'rgject Cost: S /,000 QQ 0 Paid in Full 0 Outstanding Bakince Due:
r �
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Numbcr Expiration Date
Name of CSL Holder
List CSL Type(sae below)
No. and Street Type Description
U Unrestricted Buildin s up to 35,000 cu. ft.
R Restricted 1&2 Fntnil Dwcllin
City/Town, State, ZIP IVI Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
'fele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or II1C Registrant Name
No. and Street Email address
City/Town, State, ZIP Telephone
SECTION 6: WORKERS' COI9IPENSATION INSURANCE AFFIDAVIT(M.G.L. e. 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
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.
Print Owner's Name(Electronic Signature) Date
SECTION 7h: 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 Ow er' uthorized Agent's Name(Electronic Signature) ate
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 M.G.L. c. 142A. Other important information on the HIC Program can be found at
svwwmiassoov/oca Information on the Construction Supervisor License can be found at www.rnass.eu�':'dps
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. fit.) _ Habitable room count
Number of fireplaces_ Number of bedrooms _
Number of bathrooms Number of halr/baths
Type of heating system Number o(decks/ porches _— —
1)'pe orcoohng systeut_—_-----_. Enclosed_ - ----_--Open _ --
3. `-fot,tl Project tiyuare Pootnge" inuy be sub;tihdeJ for"-total Project Cos[
r CITY OF S�1.U.Nf, -L-1SSACHUSETTS
BL:MDL\G DEPAR"M&NT
:taw ;\. 120 %VASHNGTON STRE "ET, 3 FLOOR
TEL (978) 745-9595
KIMBERT EY DRISCOLL Rux(978) 740-9M
1NLWOR THO,%W ST.PtERRE
DmECTOR OF PCBuc PR0PER'IY/8CIIDDJG COtp(tSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance will, the sixth edition of the State Building Code, 780 CMR section 1 t L5
Debris, and the provisions of NfGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
t 11, S 150A.
The debris will be transported by:
(name of hauler)
'['he debris will be disposed off in
(name of facility) —
- --(address of t'acilily)
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perm,[applicant
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CITY OF S.ULB.tiI
PUBLIC PROPERTY
DEPARTMENT
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HOMEOWNER LICLNSS EXE.MffJ0,V
Plow Print
Dam 1 A2 3
lob Location 3,31a J e e r Av-t
Ham OwnwAddrese a al��o
Home Owner Telephone
Present Mailing Addrm o oS o I G?0
The cumat exemption of"Homeowners"was euttasded to include ow nw-occupied
dwellings of two Units or fear and to allow such homeowners to engago an individual for
him who does not possess a license provided that the owner acts as supwWsa
DE INMON OF HOMEOWNER
Person(s) who owns a pored of land on which WAS resides or Intends to reside. on
which there ir6 or is intended to be6 a one or two &m4 dweWnp attached or detached
structures accessory to such use and/or rum squcturee, A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building OQfcial, on a fora acceptable to the Building
Offlci4 that hashe be responsible for all such wort performed under the Building
Permit
The undersigned ••lfomeownce assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undeniped "homeowner'certitles that hashe understands the City of Safes
Building Department minimum inspection procedures and requirements and that hash@
will comply with said procedures and requirements.
HOMEOWNERS SIGNATLAB
.APPROVAL OF BUILDING NSPECT R
Sce other lido far state code