8 MALL ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board Of Building Regulations and Standards CITY OF
di ( Massachusetts State Building Code, 780 CNIR SALEM
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Hur 20/1
One-or Tivo-Family Dwelling
This Section For Official Use Only.
Building Permit Number:
DateAp lied: 2'-03, i .
L7uilding Olticial(Print Name). - � .�
. ; Signature- .
SECTION I:SITE INFORMATION Date
„J - ,(rJrty Adress:
n 1.1 Assessors Dinp 8c parcel Numbers
I.la Is this an accepted street? es _
Y no Map Number Porcel Number
1.3 Z—airg"':formation:
1.4 Property Dimensions:
Loning District Proposed Ue�--
Lot Area(sy tt) Frontage(It)la Building Setbacks(ft)
Front Yard Side Yams
Provided Re
Required Provide) Rear Yard
Required wired
y Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 NOW Zone Information: 1-8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal❑ On site disposal system ❑
2.1 Owne I of Record- SECTION 2: PROPERTY OWNERSHIPI
"v,,�t iunl �PP�OlYn¢ � -F .SP.CaI Fla �r✓ N
/D ny,anne,ZIP
-Ny6a
No :a,ust cis _ OLr�Dy6�tauSe3 C
Telephone LmaJ AJdress
SECTION 3: DESCRIPTION OF PROPOSED WORK](check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ rs Re ai s
Demolition P � Altemtion(s) ❑ Addition ❑
Accessory Bldg.❑ Number of Units
Brief Description of Proposed Work':
0.0 Other ❑ Specify:
!I D I
a CI c; E aT. P P 5 ror
n l F one. T r
SECTION�: ESTIbIATED CON RUCTION COSTS
Item Estimated Costs:
Labor and Materials) Official Use Only
I. Building $ 000 I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S 0 00 ❑Standard City/Town Application Fee
J. Plumbing S ❑Total Project Cost'(Item 6)x multiplier 00 2. Other Fees: S x
4. Mechanical (HVAC) S QUO List:
5. �Mechanical (Fire
Su) ression) S rotal All Fees:S
6. Total Project Cost: .S Check No._Check Amount: Cash Amount
� _
� �06 ❑Paid in Full ❑Outstanding B;tlance Due:
G(� l--(_ mil\ Tzp!' C"7-0 fZ
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(M) Expiration ate
License Number P
Nanw u'CS Holder II ,jl,� List CSL'fype(see below)
fYpe Description
�]a � � �
No,and Street ,/t U Unrestricted Ouildin s u to 35,000 cu. It.)
0a� (� R Restricted 1&2 FamilyDwellin v
M Nfnson
City/Town,State,LIP RC Realm Coverin
INS Window and Sidim,
SF Solid Fuel Burning Appliances
�Z qi l,f I Insulation
s1- D -97�7 U Demolition
'I'ele hone Fnmi address C
5.2 Registered Home Improvement Contractor(HIC) 7 t�{ Ir ate
AI ti ^,t �,nrtiQ Oa �;pr[ n�}1/� HIC Registration Number P
I R� C ty1
I IIC Cuntp,)my lam•or HIC p�glsuanr is"° C Glrt h'l!
tl ( 11i�' /11/P ry ° Em-dress
N,)and Stre' r A
1' f� Tele hone
Cit /Town,State,ZIP
SECTION 6:WORKERS'CObIPENSAT[ON INSURANCE AFFIDAVIT(M.G.C.c. 152.§ 25C(6)),
Workers Compensation Insurance affidavit must be completed and sue mined with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building
p❑
Signed Affidavit Attached? Yes .......... .
SECTION 7a:OWNER AUTRORIZATION:TO BE COMPLETED W REN
OWNER'S AGENT ORCONTRACTORAIIPPLIES FOR BUILDING PERMIT`
A�(ITL1QlIn
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work an by this building perms apphc�ta r0l 13
Date
rin[Owne erne(F,ectronic ignalure)
SECTION 71h:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, f here a st under the pains and penalties of perjury that all of the information
contained in this application i orate to the best of my knowledge and understanding.
f �la)l3
- 'r"Date
Print Owner's ahorizcd A rent'.N 'Iectronic Signnuue)
NO'CES:
I. an uregistered con
An Owner who obtains a building permit to do his/her own work,or an oj'n'r/'°avwho e tires ac access to the arbitrationtmctor
(not registered in the Home Improvement Contractor(HIC) Program),
P.wsv nmus�guaranty
,oca information tion on he Construction Supervisor License rtant information
can be fo and at%v\v\v "K=1 be found at
2. When substantial work is planned,provide the information ing garage, finished basement/attics,decks or porch)
Total floor area(sq, RJ Habitable room count
Gross living area(sq. Number of bedrooms
Number of fireplaces Number of half/baths
Number of bathrooms Number of decks/porches
'type of heating system___---- Cnclosed —Open
Type of cooling system
3. -Total Project Square Footage"may be substituted for`"total Project Cosl"