11 STATION RD - BUILDING INSPECTION (2) Cr1:z#= Do
The Commonwealth of Massachusetts CITY OF
W 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
This ' hF6r�O ialU�e'Crnlv,,m�V�
s�cti' h F6r�O 4�
"tied.
BuildingPp "0.
Permit Nurnbe
J
—
Building Official rint Nam ;j , ;Signature
F-SECTION 1 E IN QWTIA
1.1 Property/Addw,.� 1.2 Assessors M Parcel Numbers
44 d
1.1 a 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,(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 El Private 11 Zone: Outside Flood Zone? Municipal 0 On site disposal system ❑
Check if yes[]
TIO
S ,17TIQ 14T P-8 7TIQ 7TIQ P Of
2.1 OwnerlofRecord:
�a- le,, AA t-915 7 0
Name(Print) City, State,ZIP
A00 a V"
No. and Street Telephone Email Address
O'P P6, I IF . - �.q: :-�
ECTION3'.,-DESC PTIGN $ED W 37� c eck'allthat, ply) ,'
New Construction 0 Existing Building 0 Owner-Occupied 0 JRepairs(s) Cl Alteration(s) 0 Addition 0
I
Number of Units Other 0 Specify:
Demolition 0 Accessory Bldg. 0 1
Brief Description of Proposed Work':SECTI Aw�
?N,4: ESTIMATED_itb CONSTRUCTION COSTS.
Estimated Costs: �
Item Official'UseOnly
(Labor and Materials)
,
1. Building $ L� Buildin P&inifTee: Indicate how fee`is determined:
aw n Applicati on.F�&._,.'
b.Slaindard'Cit
j, 1 y/T
2, Electrical $ -1 , , 3
017otA`Pi��jecl Coist�(Ifera 6),x ffiultipli6er, ?c,
o".
3. Plumbing
4. Mechanical (HVAQ $ List..
5. Mechanical (Fire
T - m $
Total All Fe
Suppression)
Check-Ampunt. Cash Amount
Check No
6. To ost: C3 Paid inTull 13 Outstanti ce Dnp-.,'
Total Project Cost: _�16)_10
lLk-, too
111 ,5,1:1
�o 0 VV/7 %a i—
SECTION 5: CONSTRUCTION SERVICES
5A Construction Supervisor License(CSL)
License Number :xpirati eYbate
Name of:CSL Holder
List CSL Type(see below)
No. and Street Type, = Desci'iptioa
U Unr Iricted(Buildings u to 35,000 cu. ft
te,Z
R stricted 1&2 Famil Dwellin
City/Town, Sta
M Mason
RC L 'n Coverin
7 W Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address I D Demolition
5.2 Registered Home Improvement Contra for(HIC)
HIC Registration Num�ExpirationJDatc
HIC Company Name or HIC Registr ame
No. and Street 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 .......... ❑ No ...........
SECTION lac OWNER AUTHORIZATION TO BE COMPLETEDWHEN
OWNER'S AGENT'OR'CONTRACTOR APPLIES FOR"BUILDINGPERMIT
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.
Pnn wner's Name(Electronic Signature) Date
SECTION.7b: OWNEW 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'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.,_mv/oca Information on the Construction Supervisor License can be found at www.mass.eov dos
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"