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0000 WASHINGTON SQUARE SOUTH - SALEM COMMON BPA 10-61 t -/ o Q The Commonwealth of Massachuscits Board of Building Regulations and Standards Town of Massachusetts State Building Code, 780 CMR, 7'"edition t� Building Dept Building Permit Application To Construct, Repair. Renovate Or Demolish a *kV@Sodwa Or - o tr)-Fumilc Dwelling This Se Lion For Official Use Only Building Permit Nurn be : Date Applied: t Signature. Building Ca issioner/Ins l' ridings Date TION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map S Parcel Numbers 7 A.LQ1 Cn a, -nJ 1.I a 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 It) Frontage III) 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.40,154) 1.7 Flood Zone Information: 1.9 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if vcsE3 SECTION 2: PROPERTY OWNERSHIP' .1 Owner'of Record, p f-/ Ex.PI/2 1lreyu Si, 5,+1- cn !.y)!} bl97� Name n0 Address fo r Sew^—� 1-1AA,�- �Ql-yap -l "'D Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek all that apply) New Construction❑ 1 Existing Building❑ Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units ❑_ Other ❑ Specify: Brief Deuription of Proposed Work': t—AnIag, Ti°A;7 i � 1 u —B L O SECTION 4: ESTIMATED CONSTRUC ION C STS Item Estimated Costs: ORlclal Use Only Labor and Materials I. Building f 1. Building Permit Fee: f Indicate how fee is determined: 1. Electrical f ❑Standard City/Town Application Fee ❑Total Project Cost (Item 6)x multiplier x 3. Plumbing f 2. Other Fees: f 4. .Mechanical (HVAC) S List: 5 .Mechanical (Fire S Suppression) Total All fees: f _ Check No. _Check Amount: Cash Amount:_ 6. Total Project Cost: f 0 Paid in Full ❑Outstanding Balance Due: SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construction Super:: 1' . Licen.e Number Expvii.on Date N;poe of CSL- Helder Lrst CSL Type Ix-c below) a ---v T I Description Address U Unrestricted(up to 35,000 Cu. Ft.) R Restricted 1&2 Family Dwellin Signature M Masonry Only RC Rcstdenual Roofing Covering Telephone w5 Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Company Name or HIC Registrant Name Registration Number Address Expiration Date Signature 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.......... 0 No...........0 SECTION 7m: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: OWNER' OR AUTHORIZED AGENT DECLARATION as Owner or Authorized Agent hereby declare Fthate statements and information on the foregoing application are true and accurate, to the best of my knowledge and me Signature of Owner or Authorized Agent Date Si ned under the ains and penalties of perjury) 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 Iff have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110 R6 and 1 I0.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. FL) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of halfibaths Type of heating system Number of decks/ porches T�pe of cooling system Enclosed Open 3. "Total Project Square Footage-'may he+uhxntutcd for 'Total Project Cost" n CITY OF S.0 EM, NLkSSACHLSETTS • BL'DDLvlG DEPARTMENT 120 WASHINGTON STREET, )'a FLOOR TEL (978) 745-9595 F.ax(978) 740-9846 tV\tBERL.EY DRISCOLL THOMAS ST.PmM MAYOR DIRECTOR OF PCBLIC PROPERTY/HL'QDLYG CO\L\D55IONER Workers' Compensation Insurance AiTidavit: Builders/Contractors/Electricians/Plumbers Annlicant Information h / Please Print Legibly Natne (Husinc� Orgvtizatiomin hvidu l): � �IJ. I/1)C, ( )O yA/ -D L0A"•'4A"t )(, P t q.t—,c a L r , Address: ! l A- it e m-t- S City/State/Zip: !S A— a H+ . A A ©If?0 Phone #: 7F'/ `re i' / Fof ,ire you an employer?Check the appropriate box: Type of project(required): I.0 I am a employer with 4. 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sul►contractors 2.0 1 am a sole proprietor or partner- listed on the attached sheet. 7• ❑ Remodeling ,hip and have no employees These sub-contractors have 8. 0 Demolition workingfor me in an capacity. workers'comp.insurance. Y P ty• 9. 0 building addition [No workers'comp. insurance S. We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3.0 I am a homeowner doing all work right of exemption per MGL 1 1.0 Plumbing repairs or additions myself.(No workers'comp. c. 152. §1(4),and we have no 12.0 Roof repairs insurance required.]t employees. (No workers' 13,.�Other 7e4n/%S comp. insurance required.) -Any applicant Ihet chocks beta of must also fill rut the waim below.showing their workers'contpemstion policy infurmutlon. r I I,tmeuwstgs who submit this affidavit indicting they are doing all work well them hire outside contractors meal auhosit a new aRtdavil indicating such. t-,,nt,wubn that cheek this box mot anachod an addidutd sheet showing the mown ,of sly subeanhwcten and their workers'comp,policy intenmtine. l am an employer that/s providinX workers'compensadon Insurance jar my employe" Below/s the policy and Job rife information. Insurance Company Name: Policy #or Self-ins. Lic. H: Expiration Date: Job Sire Address: City/Stawi2:ip: Attack a copy of the workers'compensation policy declaration page(showing the policy number and expiration date)` Failure to secure coverage as required under Section 25A of MGL c. l52 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5230.00 i day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of Irrvc,ugatiuna of the DIA for insurance coverage verification. /do hereby certify r tiiff/y�undeerrr tt hapis ain at d penalties of perfary that the information provided above is true and carrect �n�nu UrC ✓fi[ r ' G, I at Phone�: 7 F/ -, Y 0 S-- tl /O C iOfficial use only. Da not write in thin area, to be currrpleted by city or town affk•ial City or ruwn: __ Pcrmit/Llccmle#__. „ Issuing Auitionly (circle une): I. lluard of Ileullh 2. Building Department 3. C'ilyfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other LwilAct Person: .. _ _— -- Phone#'