2 SPRUANCE - BUILDING INSPECTION 1
� I �b �cIr- T056
ILI The Commonwealth of Massachusetts E- �yE CITY OF
Board of Building Regulations and�S8rNAL SERVICES SALEM
Massachusetts State Building Code,780 CMR Revised Mar 2011
r— Building Permit Application To Construct,Repair,.lMo$f%T"oohllb
One-or Two-Family Dwelling
M This Section For Official t1se Only
1 Building Permit Number: Date A plied:
1 4'�*, yid /
( Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Pro erty Ad51k�ess: - 1.2 Assessors Map &Parcel Numbers
S,tJlr'ugn GL-
1.1 a Is this an a cepted street?yes t,---ICo 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:
Public❑ Private❑ Zone: — Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: P OPERTY OWNERSHIP'
Oof ecor RfL
(Peript) City,State,ZIP
� Arn ,rzK
No.and Street .,Telephone Email Address -.
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alt eration(s A 'tion ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1. Building $ � 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
Of
2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ ' 1I
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees:$ --
Check No. Check Amount: 'Cash Amount:
6. Total Project Cost: $l6� �w 0 Paid in Full ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construf�/;n Supervisor
(CSL) - O7� 0' 7 h, h 7
�///G07 / / 1%La) License Number J Expiration Date
Nance oTCSL 1T-lolder ���
List CSL Type(see below)
No.and uzzt J�"' Type Description
U Unrestricted(Buildings up to 35,000 cu. ft.
' R Restricted 1&2 Family Dwelling
City/TbALState,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF A ��, dYi•S Q' Solid Fuel Burning Appliances
I Insulation
Telephone Email add D Demolition -
5�.22 �R{egg�istered onne ItmprovemenjJ Contrac or(HIC) y '
JCSLR NAS lion HIC'Registration Number Expiration ate
C Cbmpau Name or HIC Registrant Na e A� �&W
No. • d Sir t '1' �� � ,O�
S-5 Email address
Ct , State,22P • J 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 per L
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
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: 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
con I `d in is applicat on is true d accurate to the best of my knowledge and understanding.
Print Owner's or Authorized A nt's a(E a onic Signature) Date
NOTES: _
1. An Owner who obtains a building per-mit 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
W�ovloca Information on the Construction Supervisor License can be found at www.mass.gov/dUs
2. When substantial work is planned,prov2e 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
Ntunber 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"