52 MASON ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards OFSALEM
CITY
Massachusetts State Building Code,780 CMR, 7 h edition Revised January
Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008
One-or Two-Family DWelllng
s4it: icllil + 11,0
Tt17y_
Buil�ing:k?ertiiitTlumlier: ' '�" , �3,�i+�`p�lxe -
Signature
Building Codtmissionetllh77
s c s Sate
1.1 Pro erty Ad rase: / /� 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes nro Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
I
Zoning,District, Proposed Use - -Lot Area(sq ft) - Frontage(ft)
1.5 Building Setbacks(it)
Front Yard -- - 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:
Public❑ Private❑ Zone:._ Outside Flood Zone? Municipal O.On site disposal system ❑
Check if yes❑
2.1 Owner'of Reco d:
/� `—�— J
Name(Print) CJ Address for Service:
:z > �c - -;�vs-- �3��
Signature - Telephone .
SECTION 3 DE CRIPT1b)± (bF RI SE Vl ORic (check all that-apply)
New Construction❑ Existing Building 11 Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':_
-5 7l t� 6!J
SECTION 4. ESTEMATPD CONS IIf TIOIV.COST§
Estimated Costs: pffScialUse Only
Item Labor and Materials
e 1 Bml ft Pmilt
1.Building $ ee $ Indic'ate;how fee is determined:
M.'s-indard Citj -b 'a ApplicaBon Fee
2.Electrical $ g Toth efsl Cosl.,(ltdm¢�x mulhpligr z
3.Plumbing $ At
2 z etees;
4.Mechanical (HVAC) $
5.Mechanical (Fire
$
Suppression)
rotal„AI}Fees $
�lieck AILS Check Amount:, Cash Amount:
6,Total Project Cost: $ xaG ❑patd m<Putl„, El.Outstanding Balance Due:
SECTI(1N5 '.0 SVSIIiUw. : 'PlSEI2YICS
5.1 Licensed Construction Supervisor(CSL)
/1/I a/' 1 ,ZC L. se S' ��to�� Licen Number Expiration Date /
Name of 1CSyL-HHollder List CSL Type(see below) y
S P 1 LU-y C7 rlSCsQe '=y� ..Dbsdti ption
Address /' U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
!�-7��= 13 RC Residential Roofing Covering
Telephone WS. Residential.Window and Siding
SF Residential Solid Fuel Burninp Appliance Installation
D Residential Demolition
5.2 Re 'stege II to I tprovement Contrast� IC) fd s.S
u C 2
HIC Coryt}tan Name or C Reg t ne Registration Number
7 J-
Address
�_ .(?-312 Expiration Date
Signatureo vi -t --+a Telephone
SECTIbN 6 WORTCERS'COMPENSA tI(IN INURr1N,CE AFF112AYI1 152,§ 25C(6)1)
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...........O
SECTION 7a:dWNE AUtkORIA1?yDD L"i 101 Ell I tb1L F17f WHEN,
O V1 NEIt'S AGENT..OR:C®NT, ` GTOR AYYTSUII$U11 IIYG E�RISIIT
as Owner of the subject property hereby
authorize �'��c-� +ti� tom. to act on my behalf,in all matters
relative to work authorized by this building'permit applica on.
Si lure ofOwner - � Date
SE!i4T
I ,as Owner or Authorized Agent hereby declare.
that the statements and informatio on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
� l
Print Name
Signature of Owner or Authorized Agee Date
Si ned under the sins and enalties of r'u
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I MR5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basementlattics,decks or porch)
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 ofcooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"