19 WASHINGTON SQ NORTH - BUILDING INSPECTION j
If
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
OF SALEM
Massachusetts State Building Code,780 CMR,7th edition
1 I Revised January
Building.Permit Application To Construct;Repair,Renovate Or Demolish a 1, 2008
e- r Two-Fan;#y Dwelling
Building brmit,Number
5 Signature ;
Couvtiisaigne3'llns a o#of i„ s=
SE . <1 S TfON
1.1 Pro erty Add res : 1.2 Assessors Map&Parcel Numbers
L l 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) 7 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❑ _
n p SECTION 2;3FItO N uRSH` 'l
2.1 O�' f�ecord/J F 1,V4S'L�2q S� A"bye
Name rint)/1 Address for Service:
Signature Telephone
3ECTIaTiI;3 DESC RIP ly.4 IIiD G15) �►rdRK�(Cbecli all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:_,.
Brief Description of Proposed Work':
�G o
i SECTION 4 ESTIlY1ATLpiCOISTRIJS TIQft COS PS
Item Estimated Costs
Labor and Materialsc!?tI Use C)nly
1:Building $ 1 Bud mg PerttFee r='$ Indicate how fee is,determined:
3=Staddard CITown�i>pphcatibpFee
2.Electrical $ t0 Tti abject Costs(Ifem i)x mttltrplier x
3.Plumbing $ 2,rdtFler ?ee§ j$ ' ^T
4.Mechanical (HVAC), $
5.Mechanical (Fire -
$
Suppression) '` btal`A1tkF&gs $` _- '
he&k N4 �herk Avrount �; Cash Amount:
6.Total Project Cost: $ �l��D D paid m,Full p Outstamii,ig Balance Due: .
r
w ,z
SECTI 1+h5CQ1\ET S
5.1 Licensed Construction Supervisor(CSL) '-�
L Can r' License Number Expiration Date
Name of CSL-Holder List CSL Type(see below) I/
l /. in i ti9 OLt c� /a I) erk� r � Dbsbti ition.
Address J ^ �' (, U Unrestricted u to 35,000 Cu.Ft.)
R Restricted 1&2 Famil Dwellin -
Signature M Mason Only
RC Residential Roofing Covering
Telephone WS'. Residential Window and Sidin
SF Residential Solid Fuel Bunning Appliance Installation
D Residential Demolition
5.2 Re 'stere H to I provement ContraGt� IC) 4D (Z TyIII ILL Registration Number
HIC C E.�'n4y Name or keg t n me
c� 7
Addres� ly / D �,741," 313
Expiration Date
Signature ,r / Telephone
SECTION 6 WORKERS't UMPENSAITOL�DURANCE AFFMA TI (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 ❑
] L DMHEN -
s�cTlnN
"EWS:AGENTOR!C0NTRAGTOR 1I'P1I Sr <llRt IIH7 f!I YERIYILT:
I, T�/-7 C < as Owner of the subject property hereby
, .rs / to act on my behalf,in all matters
authorize �'27
relative to work authorized by this building permit application.
Si afore of Owner - Date
Tit O , D AC ENS D I7 tRA,TION; " "
as Owner or Authorized Agent hereby declare
that the statements and informatio on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
C.
L L
Print Name -
/ Date _
Signature of Owner or Authortzed Agent
Si ned under the erns and penalties of p I ar u
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 I MR5,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
Number of decks/
ks/porches
Type of heating system . Enclosed Open
Type of cooling system
3. "Total Project Square Footage"may be substituted for"Total Project Cost"