8 PIEDMONT ST - BUILDING INSPECTION $ -7O' cK S9z
the Commonwealth of Massachuseg,40ECTIONAL SERV CESCITY OF
Board of Building Regulations and Standards SALEM
jq,
Massachusetts State Building Code, 780 Crf)(4RFEB 29 Pl 400sedMar 1011
Building Permit Application To Construct, Repair, Renovate Or Demolish aOne-or Two-Family Divelling
This Section For.OFficial Use Only Permit Number: DateApplied.Otiicinl(Print Name) Date
SECTION 1:S INFORMATIONrty Address: ! ( I.S"Assessors blap di Parcel Numberc e all a� Jis an acce ted street?yes noM1lap Nwnber Parcel Number
ng Information: 1. roperty Dimensions:
trict Proposed Use Lot Area(sq It) Frontage(It)
ingSetbacks(R)
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 yesO
SECTION2: PROPERTYOWNERSHIP!'
Z01 i yry7
2.1 wnert of Record: A/ �Q //�(L S4 ��M i O/✓ /
.1�1jme(Pm ` - /f// City,State,ZlP
aCm6/ct�� @eAl� Lc
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) Alteration(s) 13 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Unils_ Other ❑ Specily:
Brief Description of Proposed Work': J Yn
tic 6 ) G ( l G
SECTION 4: ESTIb1ATED CONSTRUCTION COSTS
Item Estimated Costs: 7Fees:
Official Use Only
Labor all Materials
I. Building $ ing Permit Fee:S Indicate how fee is determined:
rd City/Town Application Fee
2. Electrical S Project Cost'(Item 6)x multiplier x
3. Plumbing S Fees: S4.M1lcehmtical (HV;\C) S 5. M1lechanicaI (Fire Fees:SSu ression) o. Check Amount Cash r\mount6."f Ctl Project Cust: 'S ' Full 13 Outstanding Balance Due:
-x-.
' "''i':SECTIONS: CONSTRUCTION SERVICES
A- , xssr°�2 1t�iat,t ,
5.1 Constructimt. upervisor License(CSL)
� � :•��� � (f�� diili License Number ExpirationDate-
Nmne of CSL Holder '. List CSL Type(see below)
Type' Description
No. and StreR
U Unstricted(BuildingS u -to35,000cu. 11.
It I Restricted 1&2 Family Dwelling
Citygo+vn,State,ZIP M I Masonry
RC I Rooting Covering
WS I Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Ilome Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IIIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /Town State ZIP Telephone
SECTION 6:WORKERS'.COM1IPENSATION INSURANCE AFFIDAVIT(M.G.G,c.152.$ 25C(6)y,
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Wtiance of the building permit.
Signed Affidavit Attached? Yes ..........0 No........... O
SECTION 7a:.OWNER AUTHORIZATION TO BE COMPLETED WHEN?
OWNER'S AGENT OR CONTRACT61koiPPLIES FOR BUILDING PERN11T
1,as Owner of the subject property,hereby authorize heir err FV i
t9 act on my behalf,in all matters relative to work authorized'lKy this building permit application.
oil `l,
Print Owner's Name(Electronic Signature) Dale
—� SECTION 7b:OWNER!OR AUTHORIZED AGENT DECLARATION'
By entering my name below, 1 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 A thor' ed Agent's Nano(Elec nic Sigrmlurn) - Date
NOTES:
1. An Owner who obtains a building ermit to do his/her own work,or an owner who hires an unregistered contractor
_(not registered in the Home,improvement Contractor(HIC) Program),will It have access to the arbitration
program or guaranty fund under M.G.L.c. 142A. Other Important ioTorrnation on the HIC-Program can Ne faind—at
w+v+v mass eov!oca Information on the Construction Supervisor License can be found at w++++.mas�
2. When substantial work is planned,provide the information below:
Total fluor area(sq. R.) N (including garage, finished basernent/attics,decks or porch)
Gross living area(sq. 11.) 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 rur"Total Project Cost"