73 1-2 SALEM ST - BUILDING INSPECTION 1 The Commonwealth of Massachusetts
1 Board ol'Building Regulations and Standards CITY
+ , Massachusetts State Building Cute, 780 C'MR, 7u edition OF SALEM
rr Rrvisrd Jwrmvv
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or rwu-Family Dwelling
This Section For Official Use Only
Building Permit Num gate Applied: Z414144 10
Signature: 10111 f o
Building Ciaumissia rl In f Buildings r}ute
CTION 1: SITE INFORMATION
1.1 Property Address 1.2 Assessors Map& Parcel Numbers
I.la Is this an accepted street?yes no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zuning District Proposed Use Lot Area(sq 11) Frontage(11)
I.! Building Setbacks(R)
From Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.§54) 1.1 Flood Zone Info and n: 1.3 Sewage D stem:
Public O Private O Zone: — Check if I nOZone7 Municipal O On site disposal sys O
��s-��_�(� _SECTION PROPERTY OWNERSHIP'
I 7U
2 1 Own�er�
Name(Print)/^� Adarea
SRO rokc—
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK"(check that apply)
New Construction O Existing Building O Owner-Occupied O 1 Repairs(s) Alteration(s) O Addition O
Demolition O Accessory Bldg.O Number of Units Other O Specify:
Brief Description of Proposed Work":
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OfBclal Use Only
Labor and Materials
I. Building S I. Building Permit Fee: f Indicate how fee is determined:
O Standard City?own Application Fes
2. Electrical S ❑Total Project Cosls(Item 6)x multiplier x
J. Plumbing S 2. Other Fen: S �(/C/
4. Mechanical (IIVAC) f List: f
5. Mechanical (Fire S
.Suppression) Total Afl Fees:S
Check No. Check Amount: Cash Amount:
6. Total Protect Cost: S CILp paid in Full O Outstanding Balance Due:
, r
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor ICSL)
�j_(I p��,l I.ircnx umber
Nam I:tp� Uun I to
Na ul' ' .• I IuYIJJe_r I.i9_ CSL type(see bolo
01_, Description
W a Pi
U l lnresrrkletl u to 75.000 C u.Ft.
R I Restricted 1&2 Family Dwellin
Si slat �j � �j M Masonry onl
f7��'i?Y7�GT�J�J RC Residential Rout-ins Covering
fclepMute WS Residential Window and Sidin
Si Residential Solid Fuel Burning Appliance Installatiun
D I Residenlid Demolition
3.2 Reglatere�J pme pro • Ctmt etor(HIC)
11 11 Re is �7 Reaistrouon ruzll
JJre
4�V Etpirati Dale
S' 'ldepMate
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L a 132 { ISC(6))
Workers Compensation Insurance affidavit must be c plated and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuanc f the building permit.
Signed Affidavit Attached? Yes .......... No...........0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I 4!7� 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.
a u
siatunumorowner Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
1, Rev r[ I C]fle_ as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name r/� IC
Signaturs ol'Ow oriad A 1 Uate �f/
Si umkr the aina (ties of 'u
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 ad have access to the arbitration
program or guaranty fund under M.G.L.c. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I IO.R6 and I MRS.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. Ft.) Habitable room count
Number of fireplaces Number o1'bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
). "Total Project Square Footage"may be substituted for"Total Project Cost"