2 STATION RD - BUILDING PERMIT APP \� The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
O
Massachusetts State Building Code, 780 CMR RECEIVED SALEM
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If�SPE�Ti�NAl1.ShERV CftisedMar2011
Building Per
Application To Construct, Repair, Ren vate r emo is a
One-or Two-Family Dwelling
This Section For Official Use O
Building Permit Number: Date Applied:
:-. 1 1
Building Official(Print Name) Signature Uate
SECTION 1:SITE INFORMATION
1.1 Property Address: I L2 Assessors Map& Parcel Numbers
--2- .S - /}r/o N r, d
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 Lot Arca(sq It) 14untage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Prov ided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?Public❑ Private❑ Cheek ifyes❑ Municipal 1-1On site disposal systan ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: /
MA., -ia;3 Oeu/ABC Sak-4 V4 a/S,7 a
Name(Print) City,pState,ZIP
.Z .Sl�' ! �e''� /Y. l- /�0 0��!J ��'! �I�CC�{tit013-c'.v:Nr%2✓�A'/ary
No.and Street 'telephone 13maiI Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s)tsel I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Br of Des ip[ion of Proposed Work': �.� S! OJn I-+I e.n d, s-
oALi.<1 F/ r—IA-r SO F EIYJ C)4 6-4 9,<e
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 1 1y o 0 a—� 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 $Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ Zt 6 o c' 13 Paid in Full 0 Outstanding Balance Due:
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Const uction Supervisor License(CSL)
,wC/J,/j e—/ ��;^.�•• .',�� ) P— J�x License Number Expiration Date
Name of CSL Holdbrr ?P �,,,jpjjag-ICrj�
List CSL Type(see below) (�
No.and Street Q(�D;C3 t Type Description
_ V YAN 0111
i1 l'u p f n„� G.Z U Unrestricted2 Family
(Buildings u el ing cu.ft.)
City/Town,V State,ZIP /v� ! R Restricted 1&2 Famil Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
9y G y {,_ /� C _ ,ty,, SF Solid Fuel Burning Appliances
7(/ (1�f0 6�t� /4>I C "(t�/> UN1/L I� •w. I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
�o and Street E
� P��r��d mail address
City/Town, State,ZIP 7 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 permit.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION 7a:OWNER XUTHORIZATION 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:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
contained in thi appIica/ti/Qn t ue and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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.sov/dps
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"