22 WISTERIA ST - BPA (002) The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 730 CMR Revised Mar 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One- or Two-Family Dwelling
This.$ectron,For official Use Only ,
Building PermttNumber,' > D ' Applied :i
-f
Building official wrmt Name) Signa[, e `� Date
SECTION L SITE INFORMATION
1 Property Address: 1.2 Assessors Map & Parcel Numbers
� � wcSler
1.1 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) 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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private El Check if yes[]
SECTION'2: PROPERTY OWNERSHIP't`
2.1 Ownert of Record:
Name rint) City State,ZIP/
W
oZr�- tsA-e(`iC, S�, W7
No. and Street ll.... Telephone Email Address
ON 3:_DESCRIPTIO OF PROPOSED WORK' (check' at apply} -
New EEE[4j
isting Building Owner-Occupied ❑ Repairs(s) Alterations) ❑ Addition ❑Demolition cessory Bldg. ❑ Number of Units_ Other ❑ Specify: x(4
Brief Descrip ton of Proposed WorkZ:
SECTION 4; ESTI MATED'.CONSTRUCTION COSTS
Estimated Costs: Off vial Use Only„ }
Item Labor and Materials -
mg A. Build Perm $it.Fee Indicate how fee is determined:
1. Building $ ,
❑ Standard City(Town Application Fee.,
2. Electrical $ ❑Total Project tem 6)x mulhpliec x `
3. Plumbing $ 2 Other Fee"S $ ��
4. Mechanical (E[VAC) $ List,:
5. Mechanical (Fire $ Total All Fees: $
_Suppression)
Check No. Check Amount:' .) . Cash Amount:,
6. Total Project Cost: $ 0oef c o ❑ Paid in Full , 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 41 (
�� ennseNumber Eepiratwn DateName of CSL Holder pp t CSL Type(see below)No. and Street Type Description
�nUnrestricted(Buildings u p to 35,000 cu. ft,
v o Restricted 1&2 Family Dwelling
CityfPown, St , zip M Masonry
r
RC Roofing Coverin
WS Window and Sidin
SF Solid Fuel Burning Appliances
`781'77f 7�55 �9 /k V oat (/k( r�6Ati . Cc I Insulation
Tele hone Email address D Demolition
5.2 RRegistered Hotfrye Improvement Contractor(HIC) / ��� a�3
HIC Registration N ber Expiration Date
HPC of pany ume or HIC Registrant Nameo /
Rr
No and Street
91 771 7(sSTj Email address
Ci Town, State, Z10 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 [ssuan a 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 by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering fit to elow, I hereby attest under the pains and penalties of perjury that all of the information
contained s lion is true and accurate to the best of my knowledge and understanding.
Prit wner's or Autho ` g�nt's Name(Electronic 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(HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the H[C Program can be found at
wwvw.tnass.ttov/oca Information on the Construction Supervisor License can be found at www.Iuass.gov d:ps
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. ft.) Habitable room count
Number of fireplaces Number of bedrooms _
Number of bathrooms Number of half/baths
Type of heating system _ i lumber of decks/porches
Type of cooling system Enclosed _Open
J. 'Total Project Square Footage" may be substituted for"Total Project Cost" O0O ae/