13 SETTLERS WAY - BUILDING INSPECTION (2) The Commonwealth oTaa, usetts CITY OF
Board of Building RegulaStandards SALEM
Ulf
Massachusetts State Build780 CMR Revised Mar 2011
Building Permit Application To ConstrucRenovate Or Demolish aOne-or Two-Famywng
Th,i-Section For Official
Budding Permit Number
Buildmg0iffica nntName)� 3 ,,g' ignature , +_.�,' ` - Dat
;;SECTION 1' SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
_13 �P7' irl-vs /ova
1 la Is this an accepted street?yes-& no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use or Area(sq ft) Frontage(ft)
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 stem ❑
Public❑ Private❑ P P system
Check if yes❑
SECTION 2 g1�OPERTI{OWNERSHIP[ " `; six
2.1 Owner'ofRecord:
Name(Pr t City,State,ZIP
0.-%,,§ -13 Ci4 - 5G `f54
No.and Street Telephone Email Address
SECTION 3 DESCRIPTION QF PROPOSED WORK'(check afl that apply)
_..
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s)AIAlteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief escription of Proposed Work':
o ;i 'Ire -eYl S�1ha r'asel"ee ILL wiN
{s SECTION 4 ESTIMATED Co STRUCTION,COSTS
Estimated Costs:
Item x£ Offimal Use Only ;
Labor and Materials
1. Building $ G��� I: Building Permit Fee $ Indicate how fee is defermmed:
❑ Standard City/Town Apphcatron Fee
2. Electrical $ '
❑Total]?rolec4 Cost (Item 6)x run tipper, x
3. Plumbing $ 2 OtheriFees $ �`
4. Mechanical (HVAC) $ List
5. Mechanical (Fire $ TotalAll'Fees $
Su ression
Check No Check Amount; Cash Amount
6. Total Project Cost: ❑'paid in Full ❑.Outstand ng Balance Due:
SECTION 5: CONSTRUCTION SERVICES
7�—�
Construction Supervisor License(CSL)
�I L C�t�l c� t cV License Numbeer Expiration Date
erList CSL Type(see below)ag. Type: Description
r't/ 7 U Unrestricted BuildqAppliances
tY / R Restricted 1&2 Family
City/Town, State,ZfP M Masonr
RC Roofin Coverin
WS Window andSidin
SF Solid Fuel Burning I Insulation
ele hone Email address D Demolition
5. egistereed�H�/j��ne Impro(v'em(enn/,ttCoonnttractor(HIC) >p�OL7 t, dJ/)Y/"'a S/Tw� HIC RegistrationNumb
HIC Compa Na or HIC Registrant Name
=t�reet
s -5Email address
I� O/9 7� UlfP 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 ..........CP(— 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 pe �- r P(I t i/�rc/
to act on my behalf, in all matters relative to work authorized by this building permit application.
��e � r�� le c� I l 'I 3 .
PrintOwner's Name(Electronic Signature) ( Date
SECTION 7b: OWNER'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 accurate to the best of my knowledge and understanding.
1�"T ►�Ic�ia �c�
Print 9r Authorized Agent's Name(Electronic Signature) ate
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
www.rnass.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov:'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"