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The Commonwealth of Massachusetts
Board ofBuiidingRegulations and Standar&E-E""E&R41C S FOR
Massachusetts State Building Codeowea, 0tA MUNICIPALITY
q USE
�- Building Permit Application To Construct,Repair,Renovate Qr I gQshW RevisedMm 2011
(� One-or Two-Fxn Dtvellfng %\5 %W
This Section For Official Use Only
Building PennitNumber Dam
i /1 PP ,
Building 0&cial qPr tName)
. - .• 1'� Date
SECTION 1:SITE INFORMATION
1.1 Pro, rty A rre�ss� 12 Assessors Map&Parcel Numbers
Litt Is this an acccce�p(ltedstreet?yes_'no_ Map Number Parcel Number
13 Zoning Information: 1.4.Property Dimeas m.ise
ZoningDislrict Proposed Use LotAma(sq'tI) Frontage(11)
1.5 Building Setbacks(ft)
._.Front Yard - Side Yards Rear Yard -•. ..
Required ,Provided Regdved I Provided Requited Provided
1.6 Water Snpply:(M G L o 4Q§54) 1.7,Flood Zone Information: 18 Sewage Disposal Systepa:
Public❑ Private 0 Outside Check if Flood Zone? Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSEW
21 Owfkr'ofRecor '-
Name(Print) city.State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WOWO(check all that apply)
New Construction❑ Existing Building❑ Owner )ccupied 17 Repairs(s) ❑ tetation(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units- j Other.GrSpecify-_
BriefDescdption of "osed work-
-- / L�"s-✓ �6 L
SECTION 4:ESTIMATED CONSTRUCTION COSTS
ItP4.Mechrmlcal
Estimated Materials)• r " Official Use Only.
ding $ Z��, 1. Building PennitFee $ Indicate how fee is determined:
trical $ ❑Standard City/fown Application Fee -
❑Total Project Cost'(Item 6)x multiplier x
mbing $ 2. Other Fees: $
(HVAC) .$ List
5.Mechanical (Fire
Su ression) $ Total All Fees:$
6:Total Project Cost $ �w�, Check No. Check Amotmt Cash Amount
13 Paid in Full 0 Outstanding Balance Due--
SECTION 5: CONSTRUCTION SERVICES
51 Coustruetion Supervisor License(CSL) i IR 7 172
License Number Expirationn/Date
Name of CSL Holder 7-19 CSL Type(see below)�e
Eric W.Palm
No.and Street Type
Description .
3 Hilton$treet
url ' to35000cu.8.
} � II Umeshided
Caltmu MA Oi970 R Restrictedl&2Famr7 Dweltm
City/rown,State,Zip - M Mwomy .
RC Reading covering
WS Window and Siding
SoldFLelBmningAPplisnces
O 33 "l t - I Insidetion
Teleltone Emalladdres D - Demolition -
5,2 Registered Home Improvement Contractor(HIC) Mon 3 �Z (e
Atlantic Weatilen�att�i:,.i,:
MCRegnhauoa ®ber ExpuetionDate
MC Company Name or 1310McifisUMNIffin AVenUe .
Salemn M 970
No.and Sheet - - Email address
atyrfown,State,ZIP Telephone _.
SECTION 6:WORIMS'COMPENSATION INSURANCE AFFIDAVIT(KGJ.a In§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidevit will result in the denial ofthe Issuance 9fibe building permit
Signed A davrt Attached? Yes.......... ! NO.......__.0
SECTION 79:0WNERAUTHORiZA11ON TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FORBUII DING PEMaT
i Q
I as Owner ofthe subjectpropetiy,hereby authorize &t rG I alto
to act on my behalf,in all matters relative to work authorized by this building permit application.
OvIG
Print Owner's Name(Electronic ) Data
f
SECTION 7W OWNEIe OR AUTHORIZED AGENT DECLARATION
BY enteringmy name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in a`p�plica n is accurateto the best ofmy knowledge and understanding.
�iw� • •�, 3 h y
Prim Owner's or Authorized Agnes Name(EtecronicSignature) - Date
! NOTES:
1. An Owner who obtains a building permit to do hislher own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),vA nar have access to the arbitration
program or guaranty fiord underXG.L.c,142A.Other important information on the HICProgram can be found at
ww"ass.eov/oca Information on the Construction Supervisor License can be found atwww.mass.eov/drs .
2. When substantial work is planned,provide the information below:
Total floor area(sq.it.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Numiber offireplaces Number of bedrooms
-Numnber-of-bathrooms Number-ofhalflbatls
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".