2-4 NICHOLS ST - BUILDING PERMIT APP Cam,
297
The Commonwealth of Massachusetts
Board of Building Regulations and Stand CITY OF
W NAL Massachusetts State Building Cod#ft SALEM
p l Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or emolish��E
One-or Two-Family Dwellize5 ( J
This Section For Official Use Only (}
Building Permit Number: Date Applied: *'
Building Official(Print Name) - Signature _ Date"
SECTION 1:SITE INFORMATION
1.1 Preperrty.Addre s,% I 0`S S�— 1.2 Assessors Map&Parcel Numbers
ic
1.1 as Is this an decepted street?yes b_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage(fl)
1.5 Building Setbacks(ft)
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❑ On site disposal system ❑
Check ifyes❑
SECTION 2:"PROPERTY OWNERSHIP'
2.1 Owner'of Record.` 0
1 o"Jt. ('Q M M
Name(Print) Ci State,ZIP
)F '7VY `l
0 and Street Telephone Email Address
SECTION 3-DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs( teration(s) ❑ Addition ❑
Demolition ❑ Accessory B Number of Units Other ❑ Specify:
Brief Descript of Proposed Work :
nIS fc <f 42 e I1
L e
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:Labor and Materials " Official Use Only
1.Building $ (`a O'z 0 1. Building Permit Fee:.$ indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
.❑Total Project Cost'(Item 6)"x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No. - Check Amount: Cash Amount:
6.Total Project Cost: $ t 2 1 U� t)` 0 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 09q �qq 2
?,, b.2t'4- Po C2 O 4)0 License Number Expiration Date
Name of CSL Holder
1<7 2 t J ��`e�5 �� List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
p ( WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement�onto', r(HIC)
ff''�z HIC Registration Number Expiration Date
HIC Com an Rr C RA��aag�[[Dame J(,n ,o i -t
P Y�u � CI%W�'D"� 1" G.
No. treet T
$ re �,r,�.y M��. O'�l�� j_ 6 Email address
City/Town,State,ZIP " Te1e hone
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
I,as Owner of the subject property,hereby authorize pone t r),Q�PD-
to act on my behalf,in all matters relative two work authorized by this building p milt application.
S-p Q— W't r V �'I <? —1-F'As
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER' 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 be t of my owledge and understanding. i
Print Owner's or Authorized Agent's Name(Ele is 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 M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass. ov'oca Information on the Construction Supervisor License can be found at www.masaZg�•/dM
2. When substantial work is planned,provide the information below:
Total floor 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 half/baths
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"