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210 NORTH ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts CITY Board of Building Regulations and Standards OF SALEM Massachusetts State Building Code,780 CMR,70'a ition Revised January Building Permit Application To Construct,Repair Ren a Or Demolish a 1, 2008 One-or Two-Family ell its 5 or, v: e bFtry_ BtnldingPeunivNumber 'signature:'...' In PUN 1.1 Property Address: y/ S 1.2 Assessors Map&Parcel Numbers e X : l.la Is this an accepted street?yes✓no_ . Map Number Parcel Number 1.3 Zoning Information: 1.4`Property Dimensions: Lot Area(sq ft) - Frontage(ft) Zo �. ning District. - - Proposed Use 1.5 Building Setbacks(ft) Front Yazd Side Yards Rear Yazd 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? Municipal❑.On site disposal system ❑ Public❑ Private❑ Check if yes❑ •, si�c�'tox,x:.=rRo�� r� ;; sxl�r`,. L ._� x.12T>wper'of Reeco d: Address for Service: --7�j- Name(Print) Signature Telephone-,.,,--,—, ,.. _ QN 3 DESCRiPTTON;° }° RQ SEI;�W(tltz�3(check aj1 that apply) SDI New Constru*017 Existing Building❑ Owner-Occupied ❑ r epairs(s) ❑ Alteration(s) ❑ Addition ❑ ❑ Accessory Bldg. ❑ Number of Units_,, �" Other ❑ Specify: Demolitj0µ Units,,,. Brief ppscriptionof Proposed WorkZ:� { SECTION a ,'IMATkp,,C ISTR#II TION COSTS Estimattsa usts p(ticial-.Use Only Item Labrs,vi.?Materials - 1 Butl m PemtdFoe_ $ Iridicate'how fee is.determined: 1.Building �' D gtatidazd City�owq Application Tee $ x 2.Electrical7Ttaalroletatatemi)Yc tnglgplter 3.Plumbing. , $ 2i xY7th` pet t 4.Merboiciii (HVAC) $ t m 5 !:—echanical (_Fire $ om1 A{t F es9 "6upP _. `, gg .�. h ck 1.)p; ehgdk Amount:: Cash Amount: - - 16.Total Pro!- Cost: E3 Outstanding Balance Due:-. ..SECTIONS �C@!fi!yS'1'RJIt� hI)'t�, EI3GIC)+15, ' 5.1 Licensed Construction supervisor(CSL) M �i P L License Number Expiration Date Name off CSL-Holder List CSL Type(see below) v ' I EIS �1 , ,* Address U Unrestricted u to 3�5.D O�osol rCi uli.oFnt. , Restricted l&2 Famil Dwellin Signature J -� M Maso Only !�J�:-7(,/ S (3 RC Residential Roofing Coverin Telephone WS. Residential Window and Sidin SF Residential Solid Fuel l3arnang Appliance Installation D Residential Demolition 5.2 RegisteFe H e I proven Contrsgtor IC) 1d (o y�_ HIC Cotppan Name or C Reg nt e 4� Registration Number c� S— Address ;y/. � ,_7 ��-?r'2 Expiration Date / r. / Te ephonel Signature SEC1 fOlV b WOItCCEI1S'CpMpENSA CIQN p!IiJRANCE AFFIDAVI .(M G.L.e. 152.$ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide v this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes No ❑ 5$C"CION as csS�uxEm��rrxo�;; '� , v r(1iV(rNER'S'�iGE1VTUR=�+�N'17Rs1�TG �APP�I (C( EOR:B�IIFr11I.. :; PE L'�'^ ., ^ ` as Owner of the subject property hereby I, J dY'rYp� to act on my behalf,in all matters authorize relative to work authorized by this building"permit application. Si mature of Owner sE±e>! © lab;,? wN '. I ,finer r n> ci AxalaN: . as Owner or Authorized Agent hereby declare that the statements and informatoot on the foregoing application are true and accurate,to the best of my knowledge and behalf. L l _ Print Name / /l ,� ��IA �iC� Date Signature of Owner or Authorized Agent (Signed under the 2ains and enalhes of flu N(>'LS L An Owner who obtains a building permit toydo his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will nor 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 110.R5,respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq.Ft.) (including garage,finished basementlattics,decks or porch) Habitable room count Gross living area(Sq.Ft.) Number of bedrooms Number of fireplaces Number of halfibaths Number of bathrooms Number of decks/porches Type of heating system Enclosed Open Type of cooling system 3. "Total Project Square Footage"may be substituted for"Total Project Cost"