13 LUSSIER ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts CITY
�- Board of Building Regulations and Standards
Massachusetts State BuildingCode, 780 CMR,'7"'edition OF SALEM
Revised January
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 2008
One-or Two-Family Dwelling
This Section For Official Use Only
-�T Building Permit Number: Date Applied: r{ 2• f O
Signature: /�
Building Commis inner/Inspector of Buildings bate —�
SECTION I: SITE INFORMATION
I.I Pro a Address:, 1.2 Assessors Map& Parcel Numbers
I.I 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 fi) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Require) 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?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ow ,tot Reco d•
l Ca cranyl
Nam 't � AJdress for Serxice�
Signature Telephone_/CS)(
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief De ri tign oof�ose ork'-: r i
�I KD
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
. Plumbing S Other Fees: S
4 �
. Mechanical (fIVAC) $ List: >�
5. Mechanical (Fire $
Suppression) Total All Fees: $
n pp Check No. Check Amount: Cash Amount:
6.Total Project Cost: S (�q 0 paid in Full 0 Outstanding Balance Due:
4
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL.-1 folder
List CSL fype(see below)
Type Description
Address U Unrestricted(Lip to 35,000 Cu. Ft.)
R Restricted E&2 Family Dwellin
Signature M Masonry Only
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(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
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 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.
Signature of Owner - Date
SECTI
O
�' rN�7bb�:/1OWNE�W O`R/AUTHORIZED AGENT DECLARATION
(Q l a ,/
n t )`may ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoin6 application are true and accurate,to the best of my knowledge and III
behalf. Shet �G� CK n
Print Nam �' \ 1 l�,n �Yo I ) _ F 7_ ' 0
Signature of Owner or Authorized Agent 1 ' U Date
(Signed under the pains and penalties ofperjury)
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 trot 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 110.116 and I IO.RS, 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 halt7baths j
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"