33 SETTLERS WAY - BUILDING INSPECTION (2) \ 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
�+ ` ; 1.This'S}e4ctonForOfficial,Use,Only, �� ,��=u' *� � °'
Budding Permit Number
BuitdmgOffiaaB(Pnnt Nam e). h • (`Signature Date,
SECTION:1 SITE INFORMATTON t x
1.1 Propert Address: 1.2 Assessors Map&Parcel Numbers
Lla Is this an accepted street?yes L no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot 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 system ❑
Public❑ Private❑ Check if yes[] p p
. , •.S..E.C�TIO ' WNR HIPN2`EROPERZ1>OES
2.1 0neoeco5� �7�0/ eye s J 'a ' //A
,
Name(Print) I City,State,ZIP
33 5e7�t�e's 97dv- 2!�'y—<
No.and Street Telephone Email Address
SECTION 3 DESCRIPTION QF PROPOSED WORKz(check'all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied Repairs(s). Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bidg. ❑ Number of Units Other ❑ Specify:
Briescrip on of Propose¢ rk2:
1012
SECTION 4 ESTIMATED CONSTRUCTION COSTS ,r.
Estimated Costs
Item Labor and Materials e Offioral Use Onl
Y
1. Building $ �U Butrdp g Permit Fee $ Indicate how fee is deTermme
1 d
0Standard<Crty(iownApplicat?ollFee ,
2. Electrical $ a
❑ I:Piolect Cost (Item 6)x multiplier - x
3. Plumbing $ 2 Other Fees $ f
4. Mechanical (HVAC) $5. List 1 w
K
SuVI ress oinal (Fire $ Total All Fees $
Gheck No. Check Amount: Cash Amount
6. Total Project Cost: $ !�
��Vd Q ❑Paid in Full ❑Outstanding Balance Due
SECTION 5: CONSTRUCTION SERVICES
5.1 C structia'n/Supervisor License(CSL) cq
�F/, I License Number Exp ratio Date
Name of CSSL Holder
List CSL Type(see below) G{
No. and Street Type .�.. Description
li14t //(^-a U q-70 , U Unrestricted Buildin s u to 35,000 cu. ft.)
�`, Vy ���r l V R Restricted t&2 Family Dwellin
City/Town,Sate,ZIP M Mason
RC Roofm Coverin
WS Window and Sidin
SF SolidFuelBurningAppliances
I Insulation
Telephone Email address D Demolition
2 grstered Ho {oJ�J�e Imp/rpDvem nt C/o�n7`ra for(HIC) ,03 QG S� r7 G
i"iau'J_-(.l-vsvm--IFS-L_/1—�1_'IC�II�___ HIC Regstration Numbe:
ACC4ame , IIC Registrant `ame
Email address
Tele hone
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
[, as Owner of the subject property, hereby authorize ki -P/
to act on my behalf, in all matters relative to work authorized by this building permit application.
��
Print Owner's Name(Electroi (c 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 cur be,.of. now.._ unde.standing.
�q(', r r at? C the blest n., V Inrlge and i . M�
PeY,p r I"I I C� V1c�. A 1 i .. - y /L
Pnrtsjhpgr's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
=registered
ho obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
d in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
uaranty fund tinder iv.G.L. c. 142A. Other important information on the HIC Program can be found at
v/oca Information on the Construction Supervisor License can be found at www.mass.<uov"cps
. ntial 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"