5 SALEM ST - BUILDING PERMIT APP The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
A� Massachusetts State Building Code,780 CMR SALEM
aa� Revised Ma'2011
n Building Permit Application To Co Ito t, Repair, Renovat r Demolish a
,I One-or Ttiv -Fam'ly Dwelling
This S tion F Official Use ly
Building Permit Num r. Date Appl' d:
h311
Building Official(Print Name) Signature Date
SECTIO 1: TE INFORMATION
1.15,ry# t e 1.2 Assessors Map& Parcel Numbers
1.1 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 tt) Frontage(11)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check ifyes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 rgne 'of Record:
I���9TGY�
Name(Print) City.State,ZIP
No,and Street 'Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work'-:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:Labor and Materials) Official Use Only
I. Building $ ' oO O e/ 1. Building Permit Fee: $ Indicate how fee is determined:
1. Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Nlechanical (HVAC) S List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
d� Check No. Check Amount: Cash Amount:
6. Total Project Cost: $
0 Paid in Full ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES t!
5.1 Construction Supervisor License(CSL) eG9x?? / / �G� Z
JI& l/' ( w S License Numbed Expiration Date
Name ofCSL Holder r /
List CSL Type(see below) CJ
Type Description
No.and Street
7 YP lion P
U Unrestricted(Buildings tip to 35.000 cu. 11.)
R Restricted 1&2 Family Dwelling
City/rown, ate,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Bunning Appliances
I Insulation
rele hone Email address D Demolition
5.2 Register Home Improvement Contractor(HIC) OD � 3 k /Z
�„[¢6 HIC Registration Number Expiration Date
ITIC ypany i or HIC Registran N7 T
No.and Svygt_ l- rn ^ /cY7�-^� Email address
City/Town,State,ZIP /-t- 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
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.
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 penal ' of perjury that all of the information
contained in this application is true and accurate to the best of m nowledge and understanding.
Print Owner's or Authorized Agent's Name(Ele ro s 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 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
evww.mass.,Yov%oca Information on the Construction Supervisor License can be found at ww w.mass.eov/dns
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 Cost"