11 SALEM ST - BUILDING INSPECTION 34 (Di
i The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
I Massachusetts State Building Code, 780 CMR SALEM
/ Revised Mar 2011
L 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 A ied:
I'D ' s Job
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION o
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers c ,
9 Ma Number Parcel Number Is this an accepted street. yes no p � al
K
1.3 Zoning Information: 1.4 Property Dimensions: n,-
10
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 5ti
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 if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:n /
'Pion�- if f e w Kx t I N �!}���✓1 /'��1
Name(Print) City,State,ZIP
u AO-,i )T ULD- 3YP9
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ;L Repairs(s).9, 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Workz:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Su ression Total All Fees: $
I1 y� Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ U "/` ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Constructio Supervisor License(CSL) /D 6� rriy
p7cl� License Number Expiration Date
Name of CSL Holder UI
3 J a t ST List CSL Type(see below)
No.and y�treet(/I'� I1 3 1 Type 'Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
\1/ WS Window and Sidin
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company N e or$LC R istra N me HIC Registration Number
/ Ex imtio Date
�ei`l S 1anit�
� 4 ( 7L�,Z�,� Email address
poA
City//TToown(, State,ZIP d 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 ,,^ D
I,as Owner of the subject prope hereby authorize gll( k 71 s{Ot✓1
to act on my behalf,in all mattr ative to wor t onzed by this building permit application.
1--sa)01
Print Owner's Name(Electrons gnature) ate
SEC ON 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
taine- in this application is true and accurate to the best of my knowledge and understanding.
l/ lze /6
Prior Own uPn uthorized Agent's Name(Electronic Signature) Date
NOTES:
l. 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
11A .mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.eov/des
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 halfibaths
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"