5 PARLEE ST - BUILDING INSPECTION `� The Commonwealth of Massachusetts CITY OF
r a Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 730 CMR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use ,nly
Building Permit Number:,-, Date A l d
Date
Building Official(Print Name) s: , ',•: Igo u -
SECTION 1: SITE INFO TION . ;
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
s- IP4/tc 5!<el'
Ma Number Parcel Number
l.la Is this an accepted street? yes ✓ no p
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public El Private El Zone:
if yes[:]
SECTION 2:; PROPERTY OWNERSIIIP':S
\ 2.1 Owner'of Record:
7�' miner• S G r�c� �iAlc /+lam O/9 9G
Name(Print) City, State,ZIP
a �J77I 7Hl f s63 —`�_
ail Address
No. and Street Telephone
SECTION 3:,DESCRIPTION OF PROPOSED WORK',(che.ck'all,thataliply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proppsed Work':
SECTION 4:, ESTIMATED CONSTRUCTION COSTS..
Estimated Costs: Official Use Only '
Item Labor and Materials
1. Building $ 1 Bulldmg PermiEFee $ Indicate how fee s determined:
❑,Standazd.�ity/[own Application Fee
2. Electrical $ 060 ❑Total Project Cost'(Item 6)x multiplier - x
3. Plumbing S 2 Other,Fees
4. Mechanical (IIVAC) $ List:
5. Nlecitanical (Fire $ Total All Fees• $
Suppression)
- t
Check.No. Check Amount Cash Amount.
6. Total Project Cost: $ �j�40 O6 ❑ Paid in Full . 0 Outstanding Balance Due
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL)
License Number Expiration Date
Name of CSL I-[older
List CSL Type(see below)
No, and Street Type, sc-ription
U Unres(ric (Buddin s up to 35,000 cu. ft.
City/Gown, State,ZIP
R Res ' ted I U Family Dwellin
b[ asonr
RC Roofin Coverin
WS Window rind Sidin -
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
iration Date
HIC Registration Number E xp
HIC Company Name or HIC Registrantamr
No. and Street Email address
Ci /Town, State,ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(6)) v
Workers Compensation Insurance affidavit must be com 1 d-subtnitted with this application. Failure to provide
this affidavit will result in the denial of the I o the building permit.
poact
d Affidavit Attached? s .......... ❑ No........... ❑
SECTION,7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
wner of the subject property, hereby authorize
n my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW 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 best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) pate
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 NI.G.L. c. la?A. Other important information on the HIC Program can be found at
WWw.mass.EDy/oca Information on the Construction Supervisor License can be found at www.mass ,,ov%clos
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 bathroouts Number of half/baths
Type of heating system Number of decks/porches
type of cooling system Enclosed Open
3. `'Fotal Project Square Footage" may be substituted for`Total Project Cost"