17 DALTON PARKWAY - BUILDING JACKET as I-he Commonwealth of Massachusetts
i ly Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CNIR SALEi\I
0/1
Building Permit Application To Construct, Repair. Renovate r Den lisIt a
One-or Two-Fantilt• Dire/liu,4�
1 7
This Section For OBicia se OI ,
Building Permit Number. Date p"pplllined:
Building Official(Print N;une) Signature p
SECTION 1: SITE INFORNIAT IN
109
pert Address 1.2 Assessors hla at 1 Numbers
this.an accepted street?yes no$ff,_ Z„ Nlap Number . Purcel Nunmbcr
ning Information: I.4 Property Dimensions:
istrict Proposed Use Lot Area(sq 11) Frontage(11)
lding Setbacks(R)Front Yard Side Yards - Rear Yard
ired Provided Required Provided Required Provided
er Supply:(M.G.I.c. 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Private❑ Zone: — Outride Flood Lune? Mun ❑ On site dispowlsystem ❑Check iSECTION2: PROPERTYOWNERSHIPt
erm of Record /rf �D!/l / 6 ✓
SL.1Pr� INA o /17
Name(Pant) Uq•,Slate,LIP
No.and Street "relcphone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specily:
Brief Description of Proposed Work': _
1"1I�S l�/t/lT Ne-ez" e 6 dr, - S&/r1iG�e
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and .Materials) y
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Tula] Project Cosh(Item 6)s multiplier ___ .e
3. Plumbing S 1. Other Fees: S_
4. .Mechanical (li\'ACI S List:,__
' S. .\lechanical (Fire
Su„resstonl S Total :\II Fees: S
Check No. Check Amount: _ _ Cash Annnmt:
e. Total Project Cost: S q-,g o —j D e2 -" --
❑ Paid in Full 0 Outstanding Balance Doc:
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
Licenx Number--- -- hspimtion Date
N;ime ul'l'.SI. IInIJcr -..---------------------
List CSL T)PC(see belo\c)
pe Description
U Unrestricted(Buildings up to 35,000 cu. R.)
R Restricted 1&2 Family D%%ellin
Cityi foml'SLnc.ZIP M hhuonr
RC Roofing C'ovcrin
WS W'indow and Siding
SF Solid Fuel Rurning Appliances
I Insulation -
"I'cic hone 19nuil address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Registration Number Expiration Date
I IIC C'ompan) Name or I IIC Registrant Name
No. and Street Email address
City/Town.State,ZIP "rele hone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.1 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
1, 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 Nume(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
con�me app7li�cation is tZ//
d accurate to the best of my knowledge and understanding. � _
oa g It-
hn l \,ner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or in owner who hires an unregistered contractor
(not registered in the Hume Improvement Contractor(HIC) Program),will no 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
\\\\ \ nmi., �;y\ , ,i Information on the Construction Supervisor License can be found at�%y,k.m i,s—,,A 11p,
2. When substantial work is planned, provide the information below;
Total floor area(sq. ft.) I including garage, finished basement'attics,decks or porch)
Gross living area I sq. R.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of Inalf baths
1)pe of heating system .._... _ . . -...-_ Number of decks, porches
l'\pe of coollllt_' system Fncloscd Open
�3. "folal Project Square Footage- omy be substituted for"Focal Project Cost-Project Square Footage- may he substituted for"Fomd Project Cost-
17 DALTON. STREET
745 6590
#8 or AQ
Sr+C!
ROBERT M. RUMPF & ASSOCIATES RE : Dormer Roof Framing ROBERT
CONSULTING ENGINEERS �1-/=D 3'Lt OIllt rE2t� 3 RUMPF
101 DERBY STREET �
S&l em Massachusetts No. 6632 N
SALEM, MASS.01970 +10. �tQ's r 046
fs La4`
0
Granite Development Co.
130 Boston St .
Salem, MA 01970
ATTN : Mr. R . Gauthier
Dear Mr. Gauthier,
We have inspected the new dormer roof framing for th
referenced building & found fully adequate.
Very truly yours,
PW�e, f - /I - P
Robert-M. Rumpf , P .E .
RMR :per
-a c>
-.r
L� e
r
745-6596
tt 3EA� OF AptsJ*c"
ROBERT M. RUMPF & ASSOCIATES RE :_D-Ormer;Roof Framing ROBERT
x,17 Dalt-on-Street -� z M.
CONSULTING ENGINEERS _ -- �� 3 RUMPF
101 DERBY STREET ' Sa 1 e`m, Ma B Sd Chu s a-t`t s-',_. No. 6632
9 O t
SALEM, MASS.01970 d4 01
Granite Development Co.
130 Boston St .
Salem, MA 01970
ATTN : Mr. R . Gauthier
Dear Mr. Gauthier,
We have inspected the new dormer roof framing for th
referenced building & found fully adequate.
Very truly yours ,
,
Robert-M. Rumpf , P .E
RMR :per
x
n CO
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