14 SUNSET RD - BUILDING INSPECTION (5) The Commonwealth of Massachusetts CITY
Board-of Building Regulations and Standards OF SALEM
Massachusetts State Building Code,780 CMR,7's edition Revised January
DBuilding Permit Application To Construct,Repair,Ren vate Or Demolish a 1, 2008
One-or Two Fa ' Dwelling
le
is S g 9 td5 S ey
Bui)Qin$PertnitrNumber.
Signature aie
Bmlduig Commtssionerl fFpecf6 f B ��
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers.
Jl, L . .- .Map Number Parcel Number
.. 1'ra Is this an accepted street?yes - o_ -
lq Zoning Information: 1.4 Property Dimensions:
Proposed Use .Lot Area(sq ft)' Frontage(ft)
Zoning District.- _
L5 Building Setbacks(ft)
Side Yards � Rear Yard
Front Yard
Provided
Required
Provided Required Provided Required
1.6 Water Supply:(M.G.L C.4Q,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: — Outside$rood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ - Che*if es❑
t..
< 0`1yi4FISH•�Y f' . ./1 //
t
Name(Print) Address for Service:
Signature Telephone _
7777
SECTION 3 D7 "t)i!l 12Rf3YOSR WbRI{=(cheek all that-apply)
New Construction❑ Existing Buildir�❑ Owner Occupied ❑ Y Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory B+dg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed MirkZ: 0 6 n va
f SECTION 4 ESTIIVIA ED-CONSTRIJCTION,CO$TS'
Estimated Costs
Item Offlcwl dlse On l
Labor and Materials y
1.Building'. $r. s
t Bull uig ermtt'T $ Indicate how fee is determined:
Sta73dat& Q Tb*ri Appheanon Bee
2.Eleeiria' $ ❑TotaCi dew e aidm¢)Yt[mylhPhcr X
3.plumbing
''l�a5t*'x3a .i N
4.Mechanical 01VAC) $ „ S=
5.I4[echanical 1 °ire
$ otal Al1,Fees $
Su ression v _ tChecic ND; Check Amount: Cash Amount:__
6.Total PrA jeet Cost: $. g - ❑Pard ln;Full CI Outstanding Balance Due:..
f
r, .
.,s>,eTlalvz� y. Oxsmx��Ilro�z Ei�vlc�s °: ,.
5.1 Licensed Construction Supervisor(CSL) --7
L to 64— License Number Expiration Date IY'
Name of CSL-Holder List CSL Type(see below) l/
TD
AddressUnrestricted u to 35,000 Cu.Ft.Restricted 1&2 Famil DwellinSignature Maso Onl-7%_� / �j 3 Residential Roofin CoverinTelephone Residential Window and SidinResidential Solid Fuel Bumin A liance Installation
Residential Demolition
5.2 Re 'stere H to I provement Contract� IC) �—
HIC Corytpany Name or EUC Re t tt re G Registration Number{ Jl
Address a �— /
G �,� �k�(�(�(�-?� Expiration Date
Signature Telephone .I
SEGTI01V 6 WOItT{I RS'COMPENS¢TIQN INSURANCE AFFID?:1 IT::(M G
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...........❑ -
5Fi�'Ci4)J�17a
`OWNER'S AGENT.OR CQIYLRACTOR ARP I St <dI1=B II7 INS PE1t11Z1T
I as Owner of the subject property hereby
authorize G �ti� ."`� to act on my behalf,in all matters
relative to work authorized by this build g ep rmit application.
Si nature of Owner Date /
SE4)rIi71Vb.3 ly>v £S?° nCI ) �1�s)1�1 TSE(iLAbPi:, .
JA./u p p as Owner or Authorized Agent hereby declare
that the statements and informatiorron the foregoing application are true and accurate,to the best of my knowledge and
behalf.
c, l
Print Name /,�/7//
,
Signature of Owner or Authorized Agent Date
Si ned under the vain and enalries of er u
NQT
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 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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"maybe substituted for"Total Project Cost'