40 RAYMOND AVE - BUILDING PERMIT AP The Commonwealth of Massachusetts CITY OF
UZI
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CIVIR Revised Mar 2011
VI I I Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tevo-Family Dwelling
1 -this;Section For Official Use Only
IBuilding Permit Number Date Applied
t t
Si nature „ ate
Building Official(Print Name) g
SECTION 1. SITE MA
INFORTION
1 1 Pr perty Address: 7� 1.2�Assessors Map& Parcel Numbers
7 !�
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 ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided
Required Provided 9 -
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 yes❑
SECTION�2:', PROPERTY'OWNERSHIP'.77 7 `
2.)nOwn�er�f ord: t
Name 1(Print) City,State,ZIP
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF,PROPOSED ''WORl{ (cheek'all that apply) -
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ I Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work : \
SECTION 4: E$TIMATED.CONSTRUCTION COSTS
Estimated Costs: Official Use Onlye, ,
Item Labor and LMaterials
1. Building $ $ Vl� 1 Building Permit.Fee $ Ind icate.how fee ts:determmed:,
❑,8tandardCtty/Town Application Fee
2. Electrical S ❑T-66I Piolect Cost'(Item.6)xmultipher, x'
3. Plumbing
$ 2 Other Fees $
4. Mechanical tTIVAC) $ L Lst
5. Mechanical (Fire TotaC:llPFees: $
Suppression
Check No. Check Amount Cash Amount:.
6. 'rotal Project Cost: S � 11 Paid in.Full ❑ Outstanding Balance One:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
e') a 0^ List CSL Type(see below)
No. and Str et_ "'J Type _ Description
SU Unrestricted(Buildings u2 to 35,000 cu. ft.)
City/Town, State,ZIP R Restricted 1&2 Family Dwelling
NI Masonr
RC Rootin Coverin
WS Window and Siding
l• �l C,t� SF Solid Fuel Burning Appliances
I Insulation
"reie hone Email address D Demolition
5.2 Registered Home
�Imerovement Contractor(HIC) L
) )
umber Expiration
/.6//3,
HI�C,COomp'any Name�ojllY\.AVN J ant Name
W qc
No. an 'St�re'�},, _ - ( ^�`'
mail address
Ci /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
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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I 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. J
Print Owner's or Authorized Agent's Name(Electronic Signature) 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 m the Home hnprovement Contractor(H(C) Program), will not have access to the arbitration
program or guaranty fiord under M.G.L. c. 14'?A. Other important information on the H[C Program can be found at
ww'sv.mass aoviocn Information on the Construction Supervisor License can be found at www.inass uov,il s
2. When substantial work is planned, provide the information belov.
Total floor area(sq. It
(including garage, finished base n nt/aa" decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of tlreplaces 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"