25R LYNDE - BUILDING INSPECTION P
The Commonwealth of Massachusetts
to Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revise ar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
- - This Section For Official Use Only
adding Permit Number: D Applied:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1' opertAdldres�:� 1.2 Assessors Map&Parc Numbers
1.1 a Is this an accepted street?yes no Map Number Parcel Number _
1.3 Zoning Information: 1A Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(11)
1.5 Building Setbacks(ft)
Front Yazd 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?
Public❑ Private ❑ Check if yes Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSFIIPr
2.1 O nern f Record:
-rYeti c*, Lcs&sf kdawJ Sette,vkl 04A 0 2
Name(Print) City,State,ZIP
tiIr Sc/"o1 f S 6c10 4 �)1' son tit rJ eikyee-64 i®f � l. Lbh
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WOR]e(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) V I Alteration(s)#V Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed WorkZ: 4.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:Labor and Materials Official Use Only
1. Building $ 0 D 0 1. Building Permit Fee: $ Indicate_how fee is determined:
❑Standard City/Town Application Fee
2.Electrical - -
ao
❑Total Project Cost(Item 6)x multiplier x
3. Plumbing $ 3 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ _
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount
6. Total Project Cost: $ ,� D 00 0 Paid in Full 0 Outstanding Balance Due:
i
0` Mike Becker
IATL Ic QQ ST Director
HOMES 1
Atlantic Coast Homes,LLC. Office 978-406-6800
48 School Street#2 Cell 978-590-4181
Salem,MA 01970 beckerrealty@gmoil.com
Fax 978-7774182
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 7 `ig /t
r 6 U, 6 Iri(IO& `/ License Number Expirationa "'(Da
Name o�—�f-CS'f Holder
/ / 7 � List CSL Type(see below)
No.and eet Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/rown,State,zfp M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2�!gist red Aome Improvement Contrite or(HIC)
HIC Registration Number Expiration Date
HI pl y N or HIC�Legis an ame I y
No Street ;^`I�� �l I#
14 w Email address
Ct /Ton, Tate,ZIP 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
` SI,as Owner of the subject property,hereby thorize�P!(i
to act on my behalf, in all matters relativ to ork auth rized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNERt 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 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 Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under MG.L. c. 142A. Other important information on the HIC Program can be found at
www.mass.sov/oca Information on the Construction Supervisor License can be found at www.mass,gov/dus
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch)
1 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"
i
CITY OF SM E.M, N'LxSSACHUSETTS
BUELDLNG DEPIRT'NMNT
P 130 WASHNGTON STREET, 3'D FLOOR
TEL. (978) 745-9595
FA.r(978) 740-9846
tU_NffiFRt RY DRISCOLL
NMAYOR THOMAS ST.PtERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\massiONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL 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
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed o/f� in :� /z "( L r
(name of facility) ��
(address of facility)
4nature ermit applicant
date
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