12 CHANDLER STREET - BUILDING JACKET The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Cade, 780 CMR SdMar Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date plie
uilding Official(Print Name) Sigllatu Date
SECTION 1:SITE INFORMATIO
1.1 Property Address: 1.2 Assessors Mapl2tar el Numbers
1L 6"'bu-z- 5' LIF
l.la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Sf�
Information, 1.4 Property Dimensions:
Fx�T
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 yes❑ Municipal VOn site disposal system ❑
SECTION 2: PROPERTY OWNERSH.IPt
2.1 Owner'of Record•
C ,,, LCL L y a,7 p, /-zA- OI S yo
Name(Print) p ,city,State,ZIP
3 Ehrs 6711 S�B-7 �57g rpeAo A:abw2e,-u , e,,s9.w
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) elAlteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ I Other ❑ Specify:
Brief Description of Proposed
Work: cgry t,,.e. k'le4"/ ,",tom,$ Gdo2. , (b:: ,�.
yJB✓ b4A , r1,(7� A,*,., ar/A�/r5 �, [7A n•f J .d0 a,.SL AAV4M J An...rf+7�
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ L Dm0'D 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ 1 �o.p ❑ Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 3 coo 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount
6.Total Project Cost: $ 0 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 5-' (�•-
�r' License Number Expiration Date
Name of CSL L f
4-7 �1� �� List CSL Type(see below)
No.and Str [ Type Description
,/! U Unrestricted Buildin s u to 35,000 cu.ft.
C_�{ _1YT �/76 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Mmonry
RC Roofing Coverin
WS Window and Siding
�q f/fJ SF Solid Fuel Burning Appliances
�0`017aIreD ®aol. Cut I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration N er Expiration Date
MC Company Name or RIC Regi rt 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 ..........e No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as O r of the subject property,hereby authorize 'l/an�b( �p('ej—
to act o my behalf,in all matters relative to work authorized by this building permit application.
r 44� 7- z2- ) --
Pri wner's Name(Electronic Signature) Date
SECTION 7bi OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name low,I y attest under the pains and penalties of perjury that all of the information
contained in this ap cation s[me and accurate to the best of my knowledge and understanding..
Print Owner' u ri Agent's Name(Electronic Signature) Date
NOTES:
1. 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(RIC)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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
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 Cose'
�� 12 Chandler Street.,
Plans must be filed and approved by the Inspector o7,7 J ,5
prior to a permit being granted
�j CITY OF SALEM
No.
Ward
HISTORIC DISTRICT? Y N � � Date—_-.L/[,
IF FOR SIDING, HAS ELECTRIC Home Phone 70q - 6 07
PERMIT BEEN OBTAINED? Y N Bus. Phone
APPLICATION
FOR
PERMIT TO r� L.,, , ( �
TO THE INSPECTOR OF BUILDINGS: J
The undersigned hereby applies for a permit to build according to the
following specifications:
Owner's name and address 6eY
Architect's name
Builder's name
Location of building, No.� C
What is the purpose of building?
If dwelling, # of units? � Material of bldng? wap D
Will building conform to law? , /Asbestos? OV
Estimated cost I DOv City LiLie.# State Lie.#
Signature of Applicant
SIGNED UNDER THE PENALTY OF P RY
DESCRIPTION OF WORK TO BE DONE
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Sf � �' e�^r HO�S� Y� Cti✓a �6-- Gu�''E2c
7-
SH ET ROCS T= P-OnM IE 1P7 S1 '>pIr-
Mail Permit to:
�2 CHWN'DL�d2 CT 51�1.,EV"1
No. "'� Ward
APPLICATION FOR
PERMIT TO ROOF
REROOF OR INSTALL SIDING
t
Location z� l
w ^Y
PERMIT GRANTED c
19/
Approved
Building Insp t r
m