14 PHILLIPS ST - BUILDING PERMIT APP (002) nn t 7
The Commonwealth of Massachusetts
r 4 OF
Board of Building Regulations and Standards CITY SALEM
IW 1 Massachusetts State Building Code, 780 CNIR dMar
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section:ForOfficial Use Only
Building Permit Number.,' Date Applie
Building Official(Print Name) Signature - - Date
SECTION 1: SITE INFORMATION
1.1 PropertyAd ress• 1.2 Assessors Map & Parcel Numbers
t4 �� �/lsr�•
1.l a Is this an accepted street?yes--x no Map Number Parcel Number
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?
Public Private ❑ Check if yeso-/v0 Nlunicipal)!f On site disposal system ❑
SECTION 2:, PROPERTY'OWNERSIIIP�
2.1 Ownert of Record:
/(/o r-I'L. C/'0. VMt'e S \ I L—C. S C CD-& Gc,/A C.) ( 2 tz� �L
Name(Print) Ooala �,� ¢.ram City,State,ZIP y�
/Cow t�..✓2�t{ /�.� �c.Q • ZU-3�g d-6Yt' CGL—e C pl¢t.va ?9` & \nr.
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF.PROPOSED WORK''(cbeek all that apply),
New Construction ❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition El
Demolition Isr Accessory Bldg. ❑ Number ofUnitsyQ_ I Other ❑ Specify:
Brief Description of Proposed Wor 2: ¢ e h a JL. o
SECTION 4: ESTIMATED CONSTRUCTION COSTS-
Estimated Costs:
[ten Official Use Only-_.
Labor and Materials
1. Building 7 Uv p 1. Building Permit.Fee $ Indicate how fee is determined:
❑ Standard.City/Town Application Fee
2. Electrical $ ,
- �" � ❑ Total Project Cost'',(Itern 6)x multiplier x
3. Plumbing Ofi O 2 OtherPees: S
J. Mechanical (EIVAC) S O v O List: /
5. \-lech:utical (Fire S
Su> ression) Total All Fees: S
Check No. Check Amount: Cash Amount-.
G. 'I'otal Project C'ust: S ! Q'ro O O ❑ Paid in full ❑ Outstanding 13aLmce Due:
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Conshntction Supervisor License (CSL)
\ C C�-e 20 �� __ License Number BapirationDate
Name of CSL Holder
List CSL Type(see below)
113
Le Type Description
No. and Street
U Unrestricted Bt ildirnes up to 35,W0
y R Restricted 1&2 Family Dwelling
City/town, State,ZIP \I Masonry
RC Rooting Covering
WS Window and Siding
C,,fF- A1.1- rrr?'/t SF Solid Fuel Burning Appliances
999G7 I Insulation
rI cle hone Email address D Demolition
5.2 Registered HomeeImprovement Contractor(IIIC)
/v A HIC Registration Number Expiration Date
[TIC Company Name or FIIC Registrant Name
No.and Street 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
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.
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
acne m is a and accurate to the best of my knowledge and understanding.
Print Owner's'or A fed Auent's Name(Electronic Signature) Dote
NOTES:
I. An Oeviier 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\LG.L. c. 142A. Other important information on the HIC Program can be found at
www.n ass.«owoca Information on the Construction Supervisor License can be found at www-.mass.eo�N(IL
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.)_,e (e V 0 _(including garage, finished basementlatticsy(leeks or porch)
Gross living:uea(sq, lt.l l Co o U_ Flabitable room Count ig'
Number offircplaces_ O Numberofbedr00m5 _ y _--
Number of bathrooms Number of half/baths _
rypo of heating system__--�--- Number of(lecks/porches --
I')pe of cooling system_--0 Enclosed - -------Open
1. `' focal I'noject Squ:ve Footage" wary be Substituted for"Total Project Cost"