0000 PARALLEL ST - BUILDING ABOVE GROUND POOL The commonwealth of Massachusetts
;� Board of Building Regulations and Standards CITY
I' ���' Massachusetts State Building Code, 780 CMR, 7'"edition OF SALEM
Revised Jumrenurr
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. :IXAV
One-or Two-FumilP Dwelling
This Section For M isl Use Onj
Building Permit Number: Date Applied: Ig I/Z0 1 O
Signature: -
Building Commissioner/Inspector of ildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessor Map& Parcel Numbers
n Ip^< 'Nlte 1 S�Pe t n camel Ot32
L l a Is this an accepted street?yes no Map Number , Parcel Number
1.3 Zealot Information'
1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(1t)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
S
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public'® Private O Check if esO Municipal O On site disposal system
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
S-h-kpk.a P
Name(Print) Address for Service:
lis— I IS- 4
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building❑ Owner-Occupied O 1 Repairs(s) O 1 Alterations) O Addition O
Demolition O Accessory Bldg.O Number of Unit_ Other O Specify:
Brief Description of Proposed Work-:
'An11-t¢-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:Labor and MateriaOfllclal Use Only
ls
1. Building Is 1 1. Building Permit Fee:f Indicate how fee is determined:
2. Electrical S O Standard Cityfrown Application Fee
O Total Project Cost(Item 6)x multiplier x
). Plumbing $ 2. Other Fm: S
4. Mechanical (IIVAC) E List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 0 Paid in Full 13 Outstanding Balance Due:
SECTION S: CONSTRUCTION SERVICES
rN=t
censed Construction Supervisor(CSL)
I.icense Number Expiration fate
fCSI.- I lolder I.istCSL Type(see below)r Descri ion
U I unrestricted(up to 33,000 Cu.Ft.
R I Restricted 1&2 Family Ihvellin
sipature M Masonry Only
RC Residential Roolin Covtrin
feleplume WS I Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installatiun
D 1 Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
f IIC Company Name or HIC Registrant Name Registralion Number
Address Expiration Date
Signature Ttleplame
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. f 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..........O No...........O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application. -
Siumsture of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1 si P�1�,� V) t--0 J E! \—1as Owner or Authorized Agent hereby declaJand that the statements and information on the foregoing application are we and accurate,to the best of my knowledge
behalf. Sfie. ��. P �Je
Print Name I (? I ZU L U
Signature of(honer Authorized Agent Date T—
(SiWwd under the pains and penalties of 'u
NOTES:
I. 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 W 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 I I O.R6 and 110.113,respectively.
2 When substantial work is planned,provide the information below:
Total floors 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 healing system Number of decks/porches
Type of cooling system Enclosed Open
LI. 'Total Project Square Footage" may be substituted for"Total Project Cost"