1 SALEM ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards
Massachusetts State Building Code,780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Denjgj shAL 'b "Ai- $ 41
One-or Two-Family Dwelling
This Seeon For Ilseij
Building Per¢r_it Nt tbcr:., a Appfrodi.
`�Beilding OtSpal(Prft More) .$Ignahre
1 SECTf()IN 1: I��1�'O&Mi17TON
1.1 Pro e Address: 1 sessors Map&Parcel Numbers
l.la Is this an accepted street?yes no_ Map Number Parcel Number
1 Zoning Information: 1. Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage(it)
adding Setbacks(ft)
Front Yard Side Yards Rear Yard
RequireA Provided Required Provided Required Provided
E 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: PAO MTy OWNERSHIP[`:
2.1 Owner'of o
Name ; J ri State,ZIP
Noand Street Telephone Email Address
.
SECTION 3:DESCRIPTION OF PROPOSED WORKS(obeck all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) WlrAdqtion ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed World:
SSC I fON 4:ESI IR7ATED C.'ONSTRUCIWN COSTS
Item Estimated Costs: OlSeial Use Only .
(Labor and Materials
I.Building $ e 1. Building Fermi-Pte.$ Indicate how fee is detemtined
Standard City/Town Application
C3 Standard
2.Electrical $ —5-0 a ❑Total Project Costs(Item 6)x multiplier x
3.Plumbing $ Fav 2. Other Fees: $
List:
4.Mechanical (HVAC) $
5.Mechanical (Fire $ Total All Fees:$
Su cession
Check No. Cheek Amount: Cash Amount:.
6.Total Project Cost: $ Fa u d 1 ❑Paid in Wil. ❑Outstanding Balance Due:
% 2 0V3lJe10-
4i it wt � L � /�
SECTION 5: CONS' RU4MON SI€RVICIs�
5.1 onstiuction Supervisor License(CSL) L � fid S
0 License Number "on Date
Name'of C L Holder to r+
List CSL Type(see below)
and street
�� - U Unrestricted to 35,000 w.fl.
1 T'w', tQJ�� ' � �J��� R l&2 Family Dwelling
L`rty/fown'state,2IP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
e hone Email address D Demolition
5.2 egistered Home Improvement Contractor(BIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /Town State ZIP Telq hone
SEC I10N 6;WQRI+;ERS''C�sA710N PWRANCE AAFMAV'IT(NLGJL c 152.§ 25C(8))
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...........❑
SLCC'T OX las OWNER AUTB MA TO BI COAIPLETEA®1'BEIV
QWNLR'SAqWRC: QR 1F ,R .'' QMMIT
1,as Owner of the subject property,hereby authorize �,T L N f ✓�—/� G e w
to act on my behalf,in Zattenrs relative to work authorized by this building permit application.
Owner's Name(Electronic Signa ) S t�� ate
SECTION 7B:OWNEW OR AUTHO#MED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
con " ed" "s lication is true and accurate to the best of my knowledge and understanding.
er's or Au rued A t Name(Electronic Signature) aAe
St
IV An Owner who obtains a building permit to do his/her own work,or an owner who hives an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)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.sov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dns
2. When substantial work is planned,provide the information below: '
Total floor area(sq.ft.) (including garage,finished basementlattics,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"