10 WHITE ST - BUILDING INSPECTION (19) The Commonwealth of Massachusetts
j 1 Board of Building Regulations and Standards
CITY
Massachusetts State Building Code,780 CMR, 7`" edition OF SALEM
Revised January
Building Permit Application To Construct,Repair, Renovate Or Demolish a 1, 2008
One- or Two-Family Dwelling
This Section For Official Use Only
gilding Permit No eerrJ� ,, Date Applied:
signature: ' "'Q /// d11d
h Building CommissioneLyInspector of ildl s - Date
1
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
10 WHITE STREET 41 283,284,298
1.I a Is this an accepted street?yes YES no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
I TEMPORARY OFFICE SPACE 79,715
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
5 50+ 5 50+ 5 50+
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: V3 Outside Flood Zone?
Public J I Privat� Check if yes0 Municipal J Un site disposal system❑
I• I SECTION 2: PROPERTY OWNERSHIP' I• I
2.1 Owner'of Record:
BHCM,INC. 10 WHITE STREET SALEM,MA 01970
Name 1Ari � Address for Service:
'�'/�/ 978-740-9890
Si ature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construetio Existing Buildin Owner-Occupied Repairs(s) Alteration(O Addition
Demolition Accessory Bld Number Of Units Other ✓ Specify:TEMPORARY OFFICE TRAILER
Brief Description of Proposed Work 2:OBTAIN A PERMIT FOR TWO RENTED OFFICE TRAILERS ALREADY ON PROPERTY WHEN
PURCHASED BY BHCM,INC(1 0/412 01 0). THE TRAILERS ARE ADJACENT TO EACH OTHER AND CONNECTED BY A FIVE FOOT PASSAGEWAY.
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Labor and Materials Official Use Only
1. Building $0 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $
❑Total Project Costa(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (1-IVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $0 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
Zicensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-Holder
List CSL Type(see below)
Address Type Description
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
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 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature 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 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to work authorized his building permit application.
Signature of Owner Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
1 NOAH FLAHERTY,VICE PRESIDENT AND GENERAL MANAGER OF IiHCM,INC. ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
NOAH FLAHERTY
Print Name
10/142010
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury
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 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"may be substituted for"Total Project Cost"