2 SETTLERS WAY - BUILDING INSPECTION (2) 1 The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
'�;' Thts Section For'bf#icial�Use Otily ^.�,�..,� �" "� '".n % • . __ ,.?
Bu 1ding Permit Number bate . lied
BuildmgOffic,ali.(PnntName)', ,s, ,,',,;3 $ig'natur ,r, _ Date
1 SECTION;' SITE INFORMATION . ��-.�,
1.1 Property Address Se77l-er$ `/W)al 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes� no Map Number Parcel Number
1.3 Zonirg Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(8)
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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑ p p y
.SECTION 2 PROPERT3t OWNERSHIP'=
2.1 Owner'of Record:
,��e 16,fa 0 '061n e z 5��� ifila GI9 7o
Names(Print) City,State,ZIP
�•- r�
I7f�7�0"_Q
No. and Street Telephone Email Address
SECTION 3zDESCRIPTION.OF PRtjPOSED WORKZ(cbeck'all that apply) 01
x
New Construction❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Des cr' lion of Proposed WorkZ
SECTIO V 4 ESTIMATED CONSTRUCTION COSTS,
Estimated Costs
Item Labor and Materials) .':'r..
ar Vy.officralU se nly
O <, n
$ JI :>1 Butldmg Permit Fee $ Indicate how fee is det'ermmed
1. Building Ccc G C
2. Electrical $ O Standard' Crty(Tow ApphcaEion Fee a
q Total Prgdecf Cost',(Item 6)x iaulttphex �x
3. Plumbing $ 2 Other Fees $
4. Mechanical (HVAC) $ Lrst
5. Mechanical (Fire $ �.Total'Ali
Fees $
Stippcession
Check No. Check Amount', Cash Amount
6.Total Project Cost: $ (JC/. C
r'✓J ❑Patd in Full ❑Outstanding Balance Due. "
SECTION 5: CONSTRUCTION SERVICES
a. n''sh action Supervisor License(CSL) n
License Number ExpirAtion Dale
Name of CSL Holder r
—/rat 17 F/ /�✓P -SC7--.
List CSL Type(see below) (.�f
No.and/Street (V V Type Description
S� en4 I O/ 7� U Unrestncted(Buildings u to 35,000 cu. ft.
Ctty/Town, State,ZIP cY / R Restricted 1&2 Famil Dwetlin
M Masonry
RC Roofin Coverin
WS Window and Sidin
7 r7� �� SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
g ster e Hg;ne Imprgvetggnt Co tractor(HIC)
J ts1��va �iM�l
HIC Registration Number Ex iration Date
HIC�Compan Name HIC Re gi tran[Name
/ S
No. S eet , 7 a r Email address
Ct /Town, State,ZIP 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, as Owner of the subject property,hereby authorize &f" 1 1 ia_c i t
to act on my behalf, in all matters relative to work authorized by this building permit application.
1
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 penalties of perjury that all of the information
contained in this application is true and accyt e the best of y Ion ledge and understanding.
P
f-r4oec's or Authorized Agent's Name(Electronic 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 tinder M.G.L. c. 142A. Other important information on the HIC Program can be found at
%"vw.umss.gov/oc Information on the Construction Supervisor License can be found at wlwv.masa �,,ov/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"