90 WASHINGTON SQ - BUILDING INSPECTION IkCor RFF""Fri..-
1,.
Che Commonwealth ot•btdssac4iuisetT CITY OF
� Board of Build'�� Re ulations antl'Stiindards SALEM
l q"t /• Massachusetts 5t`� q"CO, 780 CMR Revised,tlur 2011
Building Permit Application To Construct, Repair, e3ckate Or Demolish a
One-or Tivo-Family Dtvelfing
This Section For Ofliciai Use Only
Building Permit Number: Date App '
Duilding Ofliciul(Print N:une). - Signature- '. - Date
SECTION 1:SITE I1,1FOR61ATIOW
I.I Property Address: 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street9 yes_ no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sy ft) Frontage(Il)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water upply:W.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage� ❑Disposal System:
Zone: Outside Flood ZT Municipal n site disposal system Public❑ Private❑ o, l3 OCheck If es
SECTION2. PROPERTY OWNERSHIP,'
2.1 Ownerl of Record* b " M O Z i 1 6
�a g'
17�me(Print) City,Slate,ZIP p
, o --7515'
I wzf t Ca 4 (7 o -'telephone r Email Address
No.and Street
SECTION 3:DESCRIPTION OF PROPOSED%VORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ 1 Repairs(s) GrI Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': 7 s P ec} ",s. b «
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials) - -
1. Building $ 1 ,0 O J I. Building Permit Fire;$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost?(item 6)x multiplier x
3. Plumbing $ 0�,O P Qther Fees: $
4.Mechanical (FIVAC) S - List,
5. Mechanical (Fire $ Total All Fees:$
Su ression)
Check No._Check Amount: Cash Anmunt:
6. Total Project Cost: $ I ��r 6 o t? ❑Paid in Full ❑Outstanding Balance Due:
StoiJ r TZ� Z t
I -
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) GS l o t —) 3-7 5 1 1 6
T--::>g
n License Number Espiranun Da e
I� ta�+.s, ,n �C
Name of CSL Holder
� c � � List CSL'fype(see belay)
21, w�S '^ Type Description
No. and Street
j ( U Unrestricted(Buildingsa to 35,000 cu. 11.j o S ti J V' R Restricted M2 Family Dwelling
Citylfown,State,ZIP M Masonry
RC Rooting Covering
Ws Window and Sidinx
SF Solid Fuel Bunting Appliances
-7s {s' .... Evl r+h..o� .C,o• I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or I11C Registrant Name
No.and Street - Email address
Ci /I'own,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 Isluance of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a-OWNER AUTHORIZATION:TO BE.COMPLETED WHEN,- "
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERb11T
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Dale
SECTION 7b:OWNERr 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.
T-�:), _ !� S
Print Owner's or Authorized Agent's Name(Elcctrontc Signature) Date
NOTES:
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(IIIC) Program);will nut have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at
www max, cov'oca Information on the Construction Supervisor License can be found at wsv++•.mass.�o+�'Jns
t 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. 11.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
'type of heating system Number of decks/porches
fype of cooling system Enclosed Open
3. "Ifolal Project Square Footage'may be substituted for"Total Project Cost'