RENOVATIONS APP. 4ill The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
r Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
1 Building Permit Number: Date plied: _
ft3 v
Building Official(Print Name) Signature Dae 1
SECTION 1:SITE INFORMATION r",}
.:
Ll Pro erty Address: 1.2 Assessors Map&Parcel Numbers '
12 Fairmount St.
1.1 a Is this an accepted street?yes X no Map Number Parcel Number _
1.3 Zoning Information: 1.4 Property Dimensions: --J
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:(1v4.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public® Private❑ Zone: _ Outside Flood Zone? Municipal N On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Emily G000dale Salem, MA. 01970
Name(Print) City,State,ZIP
12 Fairmount St. 339-927-5652 ebgoodale@gmail.com
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WOR10(check all that apply)
New Construction❑ Existing Building W Owner-Occupied Repairs(s) ❑ 1 Alteration(s) IRI I Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work2: Gut existng-kitchen. R I n window. install new
hardwood flooring, new plumbing and electrical, and new cabinets.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 17,100.00 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ 5,600.00 ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2,400.00 2. Other Fees: $
4.Mechanical (HVAC) $ - List:
5.Mechanical (Fire $ - Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 25,100.00 ❑Paid in Full ❑Outstanding Balance Due:
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1 1 Com(.),L`E:U "C T 1 Lt_ 01 M L ti
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS-083853 5/20/18
Michael Coughlin License Number Expiration Date
Name of CSL Holder
29 Eames St. U
List CSL Type(see below)
No.and Street Type Description
N. Reading, MA 01864 U Unrestricted(Buildings u to 35,000 cu.ft.
g R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
781-507-0135 mike@sdb-inc.net I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 166149 4/29/18
Summit Design Building, Inc. HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
29 Eames St. mike@sdb-inc.net
No.and Street Email address
N. Reading. MA 01864 781-507-0135
Ci /Town,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 Issuance of the building permit.
Signed Affidavit Attached? Yes ..........50 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 Summit Design Build
to act on my behalf,in all matters relative to work authorized by this building permit application.
1/4/17
Print Owner's Name(Electrnic Signature) Date
SECTION 7b:OWNER'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.
1/4/17
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 can be found at
www.maaLgov/oca Information on the Construction Supervisor License can be found at www.mass. oe v/dns
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 Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"