0020 PLEASANT STREET - BPA-12-272 WINDOWS The Commonwealth of Massachusetts
�k—�t' Board of Building Regulations and Standards CITY
Q 'J1 OF SALEM
hts State Building Code, 780 CMR, T°edition
Massachusetts Revised Junnury
Building Permit Application To Construct,Repair, Renovate Or Demolish a i• 200
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: I Date Applied:
Signature:
%4�
Building Commissioned Inspect of Buildings Date
SECTION I:SITE INFORMATION
1.1 Prope Address: 1.2 Assessors Map At Parcel Number
a C7 �L n
I.la 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 11) Frontage(11)
1.5 Building Setbacks(R)
From 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❑ Private❑ Check if es❑ p Pos y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
h D 1 o za 1 r_p PL 4-cc—
Name(Print) Address for Service:
Cl -1 & .�< t
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Buildin Owner-Occupie epairs(s Iteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Speciry:
Brief Description of Proposed Work': Q� ir,�r � -& ��AZ�„1 � ^-'rD ne
Ma S-e-rt.�Gru.a
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
❑Standard Citylfown Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees:S
Suppression)
p Check No. Check Amount: Cash Amount:
6. Total Project Cost: S ❑Paid in Full ❑Outstanding Balance Due:
A Co ���
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 01 -A,7 (M3 S f _1 2
License Number Expiration Date
Name of CSL•I folder
c ��,R f..tl f erg STPny��]�o� List CSL Type(see below)
rim Description
.Add ste s �1 --
-���, A � U Unrestricted(up to 35,000 Cu.ft.
R Restricted IR2 Family Dwellin
Sire M Mason Only
gnatu
:1 $ Z l RC Residential Rooting Covering
relephone WS Residential Window and Siding
SF Residential Solid Fuel Bunting Appliance Installation
D Residential Demolition
5.2 Regl tered Home Improvement Contractor(HIC) ® p 8
m
I IIC Company Name or HIC Registrunt Name Registration Number
,:.*,.10.-?:,2L., Teo.t2 6 — 2 3 1�
Address P
Ex iration Date
Si• uture Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 ..........O No...........❑
SECTION 7s: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.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
at b_o LY C5.1.."t- ,as Owner or uthorized A en ereby declare
are
that the statements and information on the foregoing application a true and accurate,to the best of my knowledge and
behalf. ^7��
Print Name
Signature of Owner o uthon d Agent Date
(Signed under the pains and penalties ofperjury)
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 W1 have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"