14 PHILLIPS ST - BUILDING PERMIT APP The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
f I, WMassachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair Renovate Or Demolish a
Y' One or Two Family Dwelling
This'S"eghon For Offcial Use(Only, `
t
Building Permit Number,, k s Date p�hed -1 u
Budding Of5cial(Print Name) .•.,�; *, s-Signature<.i ��,� __, Date
SECTION.Tr: SITE;INFO
RMATION
1.1 Property ddress: 1.2 Assessors Map & Parcel Numbers
1.1 a Is t_is an accepted street?yes 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
$ECTION2 ''PROPERTY'OWNERSHIP''' ,
2.1 Owner'of Rec/ord: �������n 0
Name
/r: Pa y7W Pl
(Print) City,State,ZIP
699, UQ 78 / -3eeb"91
No. and Str t Telephone Email Address
-.. - .
SECTION 3: DESCRIPTiONOF PROPOSED WORK�`(clieck all thatapply) .
New Construction ❑ 1 Existing Buildin ±==Y:
wner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ _ Other ❑ Specify:
Brief Description of Proposed Work :
SECTION 4: ESTIMATED:CONSTRVCTION COSTS
s . .
Estimated Costs: Official Use Only
Item Labor and Materials
1. Building $ 1. Building Permit dt
Fee $ `g lncate how fee'is determined,'
b Standard City(lown Apphpahon Fee �>
2. Electrical $
❑Total'Project Cost (Item 6):xmultip her.
x
3.Plumbing $ 2 Othei Fees $
4. Mechanical (IIVAC) $ List.
5. Mechanical (Fire $Suppression) Total All Fees $'
O Check'No CheckAinount Cash Amount
6. Total Project Cost: $ 5 O p Paid in Full` ❑ Outstanding Balance Due
SECTION 5: CONSTRUCTION SERVICES
rameofCSLF[older
upervisor License(CSL) JO
o Imo✓ License Number Expir tion Date
List CSL Type(see below). ,Type ,,: bescription
/� U Unrestricted(Buildings u to 35,000 cu. ft.
^ Il_hll 1� filpi U�y R Restricted 1&2 Family Dwelling
City/Town, State,ZIP I Mason
ry
RC Roofing Covering
WS Window and Siding
_ �n SF Solid Fuel Burning Appliances
I Insulation
ele hone Email addr ss D Demolition
5.2 Registered Improvement Contractor(HIC) / ` O /� -> R ` / 9
�I l i. C I � �1 S HIC Registration Number Expiration Date
HIC�m�panyNraR orHIc Registrant
Pay
No. and Stre t fc Email addre
Q-rf 11 0) 0 I q 3D SW,( Z �g 2
Ct /Town, State, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFH)AVIT(M.G.L. c. 152.§ 25C(6I
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
t avrt Attached. Yes .......... 'Sri � No.
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED.WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR`BUILDLNG PERMIT
i
I, 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.
MAC lL l / ZC /Z
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER` OR AUTHORIZED AGENT DECLARATION
F-1
e below, I hereby attest under the pains and penalties of perjury that all of the information
lication is true and accurate to the best of knowledge and understanding.
� /�orized Agent's Name(Electronic Signa ure) Date
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
%"vw.rnass.crov/oca Information on the Construction Supervisor License can be found at www.ntass.g*ov/dos
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 bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"