7 S MASON ST - BUILDING INSPECTION (3) The C'Onmonw'ealth Of MLISSaChU SCtts
Board of Building Regulations and Standards CITY OF
r r;, Massachusetts State Building Code. 780 C'MR SALEM
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Furnilt•Dn ellitkg
This Section For OI'fi•ial Use Oni
Building Permit Number: D§te Applied:
budding offimal(Print N;unc) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Nlap& Parcel Numbers
I.la Is this an accepted street?yes no Map Nwnher Parcel Numher
13 Zoning information: 1.4 Property Dimensions:
Zoning District l4oposcd Use Lot Area(sq It) Frontage(R)
1.5 Building Setbacks(B)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:( . I.c.a0.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood"Zone?
Check fifes❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownerl of Record:
Name(Print) City.Slate,ZIP
J h YN ' J
No.and Street Telephone Email Addmss
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ .Specify:
Brief Description of Proposed Work-:
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and.Materials) Official Use Only
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
'. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier
3. Plunihing S _'. Other Fees: S -----
4. .Mcchanicul III\':1('1 S List
- .
' >, 1leeltanic;d (Fire .--_-- --- -_.-_.---
tiu i,mssionl Total :\II Fees: S_
f, Total Project Cost: S 5-00r p0 Cheek No. __—('heck Anwunt: " —Cash Amount:
❑ Paid in Full C3 Outstanding Bal:utce Due:
e
SEC"?'ION 5: CONS"?'RUC"rION SERVICES
5.1 Construction Supervisor License(C'SL)
License Numhcr"--- -__ Fspiradon Dale
N:unc of l'Sl. l lnldcr
List CSI.1)
No. and.Sucel ------- -- -------- .I.y Pe Description
U Unrestricted(Iluildin,s li l0 15,000 cu. 11 )
R Restricted I&2 family IAlellin,
Citci town,\talc.LlP NI 71,—,,onry
RC Rooling Cmerin
-.—. WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
'felt hone [:mail oddness U Demolition
5.2 Registered Ilome Improvement Contractor(HIC)
IIIC Registration NUIntler Expiration Date
I IIC C'ompan) Nome or I IIC Registrant Nano
No.and Street Email addmss
CitylTown,State,ZIP rele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L it. 152.1 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...........O
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
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNERI 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 ipplication is true and accurate to the best of my knowledge and understanding.
Print Os is or:\uthoriicJ,\gent's Name(Flectro is Signature) Date
NOTES:
1. 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 Hume Improvement Contractor(HIC) Program),will 1 have access to the arbitration
program or guaranty t'und under\I.G.L.c. I42A.Other important information on the HIC Program can be fund at
m•1., n .,CO Information on the Construction Supervisor License can be found at n>l,l mass y l 1p„
_E When substantial work is plumed,pro%ide the information below:
Total floor area(sq. R.) _ t including garage, finished basement attics.decks or porch)
Habitable roost count --. --
\umber of fireplaces_-_- — Number of bedrooms
\'umber of bathrooms _- Number of half baths
hypcofheatingsystem .. ... . _. .__ Number of decks, porches
1'\(le Uf eJllhllg i%SIC 111 Fncloscd -. .. _ OHell
t. "Haul Project Square Footage"may be Substituted IUr• I'oial Project Cost"