12 WHEATLAND ST - BUILDING INSPECTION (2) 14 The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code,780 CMR, 7 h edition OF SALEM
IUII a. Revised January
" Building Permit Application To Construct,Repair, Renovate Or Demolish a 1, 2008
On -or Two- amily Dwelling
This Sect ,Fof O,flicial' 'ge Only
cuilding Permit Number- Date Applied:''. ,
Signature:
' Buildin isson r/In tor,OfB4ilc!inis T -
SECTION I BITE INF0RMAT16N'�
+ rop Addr 1.2 Assessors Map&Parcel Numbers
a .
MVM
is an accepted street?yes - no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: .
Zoning District, Proposed Use Lot Area(sq f Frontage(It)
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❑
ti °_ SECTION 2: PROPI RTY'OWNERSIIW -
2.1 O n t of Reco
�o7A T.¢�g��'S �/.ee arc C// S
Name(Pri Address for Service:
2 '!'S_- SSYS^
Signatur - Telephone
SECTION 3.1DESCRIPTION'OF PROPOSED WORK2(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repair s(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2:
T i'D �s �`/ CG /c✓�
SECTION 4: ESTIMATE,D CONSTRUCTION COSTS
Item Estimated Costs: -.;:"
Labor and Materials x , ,' °, . Official IIse Only;
L Building $ 1 .Building Permit Fee.$ Indicate how=fee ds determined:
2.Electrical $ ❑Standard"-City/Towd Application Fee'
❑TotalTroject Cost 3;(Item.6)x':multiplier x
3.Plumbing $ 2 Other Pees.
4.Mechanical (HVAC) $ List:.,
5.Mechanical (Fire
Suppression) $ Total All Fees $`
Check No: Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid,in ❑,Outstanding Balance Due:
SECTION 5 ,CONST$UCTION!SERVICES '
5.1 Licensed Construction Supervisor(CSL) 14�077 2 1L_ !�
M1Cn L ro 6L—i License Number Expiration Date
Name of CSL-Holder List CSL Type(see below) V
Address
/r, O� , U Unrestricted u a ily Dwelling Cu.Ft.
� R Restricted 1&2 Famii
Signature M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Re istere H re irprovement ContraStorIC) Id �ic�'.S'�_
HIC Co v Name or C Reg t nt ne Registration Number
Address - - Expiration Date
�A , , ) r , ,-.. 5 7k 7 f�3r3
Signature Telephone
SECTION 6:WORI{ERS'COMPENSATION INSURANCEAFFIDAVIT(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'7ii:OWNER AUTHORIZATION TO BE.COMPLETED WHEN.>
,OWNER'S AGENT OR CONTRAC/TOR APPLIESiFOR litj 1VG-PERMTI
as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative t wor authoriz by his building permit application.
21,71
SignatujlekfOwner Date
SECTION,7br:O,WNER-OR AUTHORIZED-AGENT DECLARATION
I, /) IJAi p � O14 I ,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.
G
Print Name a - '
41u
Signature of Owner or Authorized Agefrt ` Date
(Signed under the pains and enalties
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 1I0.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"may be substituted for"Total Project Cost"