17 CHERRY HILL AVENUE - BUILDING JACKET � I � l Zook
The Commonwealth of Massachusetts y
Board of Building Regulations and Standards REIC ffar2011
Massachusetts State Building Code,780 CMR i!t$PEG �HVl
ra
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling Z815 AN_15 A 8: 4
This Section ForOffic' Use Only
n Building Permit Number: Da pplied:
t A _
I
1 (1 Building Official(Print Name) Signature - Date
SECTION 1:SITE INFORMATION
1 1.1 Property Address:l�l^ 1.1 Assessors Map&Parcel Numbers
vYU ill 11 Ie
Lla 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 ft) Frontage Ill)
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 ifycs❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner'of Record:- -Richard Pelletier Salem, MA. 01970
Name(Print) 17 Cher Hill Ave City,State;ZIP
ry 978-745-5010 Rnpelletier@comcast.net
No.and Street Telephone Email Address _
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': - v-, .
i S lr1'1
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
I.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: -
5.Mechanical (Fire $
Suppression) Total All Fees:$
wsoCheck No.. Check Amount: . Cash Amount:
6.Total Project Cost: $ 13 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
\ c 1�1 �25� � e
�J �mp- l S�t('(1r1.�J,,� License Number Expiration Date
Name of CSL Holder
"" I VMa R. ) _t ^ List CSL Type(see below) U
No.and Street - Type Description
scl x ,J-A , p � �`�U� U Unrestricted(Buildings u to 35,000 cu.ft.) "
/V�✓ - R Restricted 1&2 FamilyDwellin
City/Town,Stale,ZIP -- - - --M Mason
ry
RC Roofing Covering
WS Window and Siding
+,,• SF - Solid Fuel Burning Appliances
'1�1��5 �.� Nt OtS(�PhVLViI'li�.-.rr�CAr I Insulation
Telephone Email address - D Demolition
5.2 Registered Home Improvement Contractor(HIC)
\A\J ynt mar
HIC Co �r,j-iIC,Registlant Name
HIC Registration Number Expiration Date
rpgarty1N�m
W No.an�^$„'tllt`1e.1�e�Jr,J u QWD� Email address
City/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 .........IK No...........0
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 y\V\Yl \' so\cktr
to act on my behalf,in all matters relative to work authorized by this building permit application.
Q Q 01/08/15
Print Owner'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.
Print Owner's or Authorized Agent' a(Ele nic Signature) Da e
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
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.2ov/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"
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