4 PAUL AVE - BUILDING INSPECTION i The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY SALEM
dM
Massachusetts State Building Code, 780 CMR
Revised M 2011
Building Permit Application To Construct,Repair,Renovate Or Dem a
Ir One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: D Applied:
Building Official(Print Name) - Signature Date
SECTION 1:SITE INFORMATION
1.1 P-/roper�y A dresseAr 1.2 Assessors Map&Parcel Numbers
4� /�Vr-
1.1a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Regdned Provided Required Provided
1.6 Water Supply:(M.G.L a 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2�Owner'of Record: �+ _ / /�.� q.�7
�1 l/ W r1 n e— LJZ-�C �� d'I'°/"t'\ r ' !10 S S l /
e(P` tt� City,State,ZIP
yT�,r.,
No.and Street Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) <Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work2: r / /`aa 5
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ C 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ G c, e. ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing 2. Other Fees: $
4.Mechanical (14VAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ S . Cv ❑Paid in Full ❑Outstanding Balance Due:
ket
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
91921/?
/�(rr in License Number Expiration Date
Name of CSL Holder
�(0 ytG/& List CSL Type(see below) U
No.and Street l✓ ��11 Type Description
A/rrfA A*-.ip4:N 4Z4 0/�Y R Unrestricted Buiaini su Dwellto ing
cu.ft.
R Restricted 1&2 Famil Dwellin
city/Town-State,ZIP M Masonry
RC Roofing Covering
WS Window and Sidin
rt ^ r/�, � SF Solid Fuel Burning Appliances
7 f1� -:��}— /y�— �'�Nt'—LWrf,/RcyCyr [L ncnyi I insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) Icr*� 7 3 Ir Y1�
C�'J� Cnn Sfft.Cf:pi .(-N� HIC Registration Number Expiration
HIC Company Name�r HIC Regist l�m nt Name
No.and
kv7 Acrf�
,oy,rt�tStlr�et
!?..c /Y7� GI G¢ stir-3G7-Sl�/Z Email address
City/Town,State,'ZIP Telephone
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 K C Corr f/rcx 6'c 121e, ��. a%n rot
to act on my behalf;in all matters relative to work authorized by this building permit application.
PrMMwner'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 best of my knowledge and understanding.
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Print Owner's or Authorized Agent's Name(Electronic Signature) Daze-
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 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.eov/oca Information on the Construction Supervisor License can be found at www.mass.¢ov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch)
Gross Iiving 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"maybe substituted for"Total Project Cost"
1