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CITY OF SALEM MASSACHUSETTS_
s
BOARD OF APPEAL
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MASSACHUSETTS 01970
TELEPHONE: 978-745-9595
KIMBERLEY DRISCOLL FAX: 978-740-9846
MAYOR
�I
May 4, 2011
Decision
City of Salem Zoning Board of Appeals
Petition of RENEWAL VENTURES, LLC requesting a Special Permit under Sec.
3.3.2 of the Salem Zoning Ordinance allow a change of nonconforming use by
addition of one (1) residential unit to an existing four(4) residential unit building,
and requesting Variances from lot area per dwelling unit and off-street parking
requirements, for the property located at 28 EDEN STREET (R-1).
A public hearing on the above Petition was opened on April 20, 2011,pursuant to Mass
General Law Ch. 40A, § 11. The hearing was closed on that date with the following Zoning
Board of Appeals members present: Rebecca Curran, Elizabeth Debski, Richard Dionne,
Annie Harris,Jamie Metsch (who recused himself from the hearing),Jimtny Tsitsinos
(alternate) and Bonnie Belair(alternate).
Petitioner seeks a Special Permit pursuant to Section 3.3.2 and Variances under Sections
4.1.1 and 5.1 of the City of Salem Zoning Ordinances.
Statements of fact:
1. Attorney George Atkins represented the petitioner at the hearings.
2. In a petition date-stamped March 17,2011, petitioner requested Variances from lot
area per dwelling unit and from off-street parking requirements, and a Special Permit
to change a nonconforming use, for a fifth unit in a nonconforming four-unit
building at 28 Eden Street.
3. At the April 20, 2011 hearing, six residents spoke in opposition to the proposal,
citing a lack of adequate parking and lack of space for snow removal in the
neighborhood.
The Board of Appeal, after careful consideration of the evidence presented at the public
hearing, and after thorough review of the plans and petition submitted, makes the following
findings:
1. Desirable relief may not be granted without substantial detriment to the
public good or without nullifying or substantially derogating from the intent
or purpose of the zoning ordinance, since the proposed plan would
legitimize a fifth unit in a building that lacks sufficient parking, and is located
in a neighborhood with significant parking deficiencies.
On the basis of the above findings of fact and all evidence presented at the public hearing
including, but not limited to, the Plans, Documents and testimony, the Zoning Board of
Appeals concludes:
L A Special Perrot under Section 3.3.2 is denied.
2. Variances under Sections 4.1.1 and 5.1 are denied.
In consideration of the above, the Salem Board of Appeals voted, two (2) in favor(Belair
and Debski) and three (3) opposed (Curran, Harris and Dionne), to grant petitioner's request
for a Special Permit and Variances. The petition is denied.
C��- A9rt7
Re ecca Curran, Chair
Salem Board of Appeals
A COPY OF THIS DECISION HAS BEEN FILED WITH THE PLANNING BOARD
AND THE CITY CLERK
I
Appeal from this decision, if any, shall be made pursuant to Section 17 of the Massachusetts
General Laws Chapter 40A, and shall be filed within 20 days of filing of this decision in the
office of the City Clerk Pursuant to the Massachusetts General Laws Chapter 40A,Section
11, the Variance or Special Permit granted herein shall not take effect until a copy of the
decision bearing the certificate of the City Clerk has been filed with the Essex South Registry
of Deeds.
I
iCertificate No: 619-11 Building Permit No.: 619-11 !
Commonwealth of Massachusetts
City of Salem j
Building Electrical Mechanical Permits
This is to Certify that the CONDOMINIUM located at
Dwelling Type
28 EDEN STREET
-..----.--- _ in the CITY OF SALEM
- - .. -
Address Town/City Na--
me
IS HEREBY GRANTED A PERMANENT CERTIFICATE OF
OCCUPANCY
28 -1 EDEN STREET
This permit is granted in conformity with the Statutes and ordinances relating thereto, and
expires - -__----- - unless sooner suspended or revoked.
Expiration Date
Issued On: Wed May 30, 2012
_..
GeoTMS®2012 Des Lenders Municipal Solutions,Inc. _
l
Certificate No: 619-11 Building Permit No.: 619-11
Commonwealth of Massachusetts
City of Salem
Building Electrical Mechanical Permits
This is to Certify that the CONDOMINIUM located at
Dwelling Type
23 EDEN STREET n the CITY OF SALEM
- _..-.
- -- --
Address Town/Qly Name
IS HEREBY GRANTED A PERMANENT CERTIFICATE OF
OCCUPANCY j
28-2 EDEN STREET
This permit is granted in conformity with the Statutes and ordinances relating thereto, and
expires unless sooner suspended or revoked.
Expiration Date
Issued On: Wed May 30, 2012
GeoTMS®2012 Des Lamers Municipal Solutions,Inc. -.-_..._ ....-__--
Certificate No: 619-11
� Building Permit No.: 619-11
Commonwealth of Massachusetts
City of Salem
Building Electrical Mechanical Permits
This is to Certify that the CONDOMINIUM located at
Dwelling Type
28 EDEN STREET in the CITY OF SALEM j
Address ------ ------ --
Town/City Name
IS HEREBY GRANTED A PERMANENT CERTIFICATE OF
OCCUPANCY
30-1 EDEN STREET
I
I
This permit is granted in conformity with the Statutes and ordinances relating thereto, and
expires . unless sooner suspended or revoked.
Expiration Date
Issued On: Wed May 30, 2012
— --- --._ .-- --
GeoTMS®2012 Des Ladders Municipal Solutions,Inc.
------------------------------------------------
Certificate No: 619-11
_ Building Permit No.: 619-11
Commonwealth of Massachusetts
City of Salem
Building Electrical Mechanical Permits
This is to Certify that the CONDOMINIUM located at
Dwelling Type
28 EDEN STREET in the CITY OF SALEM
AddressTown/cityNam_ Nam-a.__.-.-..--__...-.._.__..-
e
IS HEREBY GRANTED A PERMANENT CERTIFICATE OF
OCCUPANCY
30-2 EDEN STREET
This permit is granted in conformity with the Statutes and ordinances relating thereto,and
expires _ unless sooner suspended or revoked.
Expiration Date
Issued On: Wed May 30, 2012
GeoTMS®2012 Des Lauriers Municipal solutions,Inc.
28 EDEN STREET 619-11
�> # ,i s310 COMMONWEALTH OF MASSACHUSETTS
Map _
Block:5 CITY OF SALEM
Lot: ., 0595
Category: REPAIR/REPLACE ''
P rnut# ; 619.11 44 .s`� � BUILDING PERMIT
Project# , '`u` JS 2011-000845Y''" "
Est. Cost.` ;,$6,000.00
Fee Charged., x
Balance Due: $ oo PERMISSIONIS IIEREBY GRANTED TO:
Const Class: Contractor: License: Expires
Llse Group w� : jiz' ` SALEM RENEWAL LLC CONSTRUCTIO SUPERVISOR- 101745
Loi Slze(sgft)_4999.8168.,"
R1F Owner: Renewal Ventures LLC
g In
Units Gained: r' ` " 'Applicant: SALEM RENEWAL LLC
Units Lost. .,u ,', `AT: 28 EDEN STREET
Dig Safe#:'att' z
ISSUED ON: 24-Feb-2011 AMENDED ON: EXPIRES ON: 24-Jul-2011
TO PERFORM THE FOLLOWING WORK:
SELECTIVE DEMOLITION jbh
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Electric Gas' Plumbing Building
Underground: Underground: Underground: Excavation:
Service: p� er: r `� ''',,,aaa��� /// Footings:
Hou h:�i / Q,/�� Rough (�// U' / Rougloj l(� �jL�Z Foundation:
lVl/."bat Y!i
Final: l,3/ll Final: Final• Rough Frame:•
Vi
z ��� Fireplace/Chimney:n:,<r1
IA/if.0p
D.P.W..W. Fir Health
Insulatio
Meter. Oil: �
_C' AO/�
House# Smoke: Final: 2// //�
Water: Alarm:
((( (( Assessor Treasury:
Sewer: Sprinklers: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF ITS
RULES AND REGULATIONS.
Signature:
F 7ANT:OWNER OR CONTRA(MIM1111INJIT Date Paid: Check No: Amount:
IGUCTION.SEINE CURRENT B COGE�5 24-Feb-11 2753 $39.00
CHAPTER 1 FOR LIST OF REQUIRED INSPECTIONS.
CALL 978-619-5641 TO SCHEDULE AN INSPECTION
GcoTMSO 2011 Des Lauriers Municipal Solutions,Inc.
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YSOYE AO 1�
CITY OF SALEM
BUILDING PERMIT
1.
The Commonwealth ol'Massachuse«s
i hoard of Building Regulations and Standards CITY
Massachusetts State Building Gude, 730 CMR, T°edition (>F SALEM
Revised January
Building Permit Application'ro Construct, Repair, Renovate Or Demolish a 1. 20011
One-or Tui -Family Dwelliq
This ' ctio Fpr 011icial se Only
Building Permit Numb r: ,,, - ate plied:
//n \
Signature: '"'V' M./
WBuilding Commissioner/I pector of Buil Date
SECTIO 1.SIT INFORMATION
I 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
-80
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 It) Frontage(11)
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 Zu ?
Public @' Private❑ Check ifyelw Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 caner of a ord: I
Name(Print) Address ttorServqiic : I�
in
Y
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction O 1 Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition VT Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1. Building S I. Building Permit Fee: S Indicate how tee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing S 1. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
J Check No._Check Amount: Cash Amount:_
6. Total Project Cost: S f7 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) cerq
10
�)
hcensJ Num�her Fxf iml m])ate
Nameul GSl-I IuIJe �� .4` I.isl CSL 7)'pe(see below)
:Wdress fN Ve IDescription
Il IlnreslricteJ(up to 35,000 Cu. Fl.)
It Restricted 1&2 Family D%%ellin
_r//l1/ RC Residential Roofing Covering
telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
IN Residential Demolition
5.=tered ome Improvement Contractor(HIC) / —
�. ,,,.. �wn,Z,tisy�_LL i 10
11
111 ' 'p 'ny a r, r IIIC Itel islrtN ne Regi�lraton No ter
mA-
Addre -C � 9. 19TH d� io
[.< Ifann Date
Signature roephone
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
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.
Signature of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
i
I, < - ,as Owner or Authorized Agent hereby declare
that the statements pQ information on the foregoing application are true and accurate,to the best of my knowledge and
behal
Print Name
Signature of OwrWrrTr A orized Agent Date
(Signed under the pains and penalties ofperjury)
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(1)IC)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 I I O.R6 and I 10.115, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Grass living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of hal"aths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may he substituted fix"Total Project Cost"
r.
r1
The Commonwealth of Massachusetts
Ut)
Department of Public Safety
Massachusetts State Building Code(780 CMR)Building Permit Application for any Building other than a One- r Tw Family D elling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a fr t a ss is not available)
CKO
L
No.and Street City/Town Zip Code Name Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building Repair❑ Alterations I Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes No ❑
Is an Independent Structural Engineering Peer Review required? ,,�� /� Yes ❑ No ®K
Brief Description of Proposed Work: 2et,nJ 4/ Clh I'Ttr f`P��R6 OT--/'till t lLrn�'
rto K to Un;+ (nfa Z
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1❑ 1-2❑ 1-3❑ 1-1❑ M: Mercantile❑ R: Residential R-1 d' R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ ILIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
s
Public l� Check if outside Flood Zone❑ Indicate municipal A trench will osal Site❑
not be Licensed Di-�
Private❑ or indentify Zone: or on site system❑ required er trench or specify: t�]L
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: NIA I I. turn Co num„i,n i:ovi, I r xcc.:
Not Applicable 1�� Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No 92� Yes❑ No ti3'
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Cude: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
r
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
�u,ctvtl�ew{w�lL� 1'}I �.7a,ehtn 51— e�a;(ec>, M47 D79
Name(Print) No.and eet City/Town Zip
Property Owner Contact Information:
I Pab f t� 9-"
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized bv this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
�n �e So 10 5
Name(Regi, ant) Telephone No. e-mail address Registr hon Number
fb Ib ;4 ,4, ��etttte. MA D� A ZA
Street Address City/Town State Zip Discipline Expiration Date
1_0..2 General Contractor
Company Name
( Pieb CS rof ;7`15 ��
Name of Person Responsible for Co struction License No. and Type if.(Adppplicable�1 q
1`T( 0QA r J, OL9
gSt�re7et Addreo�ss City/Town State Zip
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:Ib'OKKFTCS'COMNF.NSA[JON INSUKANCT.Al FIDAVI'I M.G.L.c.152. 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ zo Of ro appropriate municipal factor)=$
3. Plumbing $ L 00D
=4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact m/'u�n'cipality)
5. Mechanical Other $ Enclose check payable to , (J
6.Total Cost $ 00 (contact municipality)and write check number here
SE ION 13:S NATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I here attest a der the pains and penalties of perjury that all of the information contained in this
application is true and accytmte to th best my knowledge and understanding.
� HAc� OfL
( ( d sign name � �/ Title -Telephone No Date
',TTl ll � h.(n�l.n'v+ l�S) I.Ww.. _l Jl_.3rt6L--
Street Address U City/Town Sate Z'
Municipal Inspector to fill out this section upon application approval:
Name EVe
The Connnomrealth of NfassachusetlS
I t Hoard of Building Regulations and S(dndaids I ul2
t ,y Massachusetts State Building Code. 7SO(':MR. 7"' edition >11 VI( II' \III l
I tit.
Huilding Permit Application To C'onsti-i ct. Repair. Reno%ate Or Demolish a Kri
Ont - or Ttru-Pamill Orll'llilly 'olIS
This Section For Official Use Only --i
Building Permit Nu e _ D;ue �pplicd: 21 O`-�_- -_---_-- -._ -
Si ena(urc - ------ --- t-� `w.--- -- - - --- - -
H ding Cum u, i el" he.;,er;or tit Huddmg, Date
---- SFt"I'l0N 1: SITE INFOR. LIAH0N _
1.1 Property Address: ------ 1.2 Assessurs Map & Parcel .Numbers ----- ._ .
Pa Numhei
!_la is chi to wcopred sticl Map NU111hel
__ --
. . .. .._...;. :__...t..r+... 1.4 Pr^-p---rt, t {,r.:rF-=ons: --I
Zoning Urnrict Proposed Use I Lot Area(sy t ) Fnnu rge!to -
1.5 Building Setbacks (fU
1
Front Yard tilde Yards Rear Yard
Required Provided Reywred Provided Reyumed Pn,s!dcd
1.6 Water Supply: tM:G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: —�
Zone: _ Outside Flood Zone' ,titunici al ❑ On site Jip,: u.ul ❑s}acm
Puhhc ❑ Private❑ Check if yes❑ P
SECTION 2: PROPERTY OWNERSHIP
' l OwnerrofR � n6-3� In
_. ( <<.�-. --
\.mPrinti Address t'or Service-
Telephone
SECTION 3: DESCRIPTION OF PkOPOSED WORK=(chec•ka II that apply)
v � � ' 0 R,:1i -/ Alterations ❑ :\JJdiu�
' v, or:,tn!cticn ❑ Existing Bwldm ❑ .,unerJccupieu ❑ � _.., airs(s) LO j ( )
Ne C
------------- -—J Deno lion ❑ Accessory Bldg. ❑ Number of Uml other 0
--- — —N.--
B icf)ressgrtion of Proposed Workr:T_I
SECTION 4: ESTIMATED CONSTRUCTION COSTS - l
Estimated Costs:
Item Official Use Only
(Labor and Materials)
I. BwIJi!7gy � I. Building Permit Pee: $ Indicate huss fee Is de(unnired:
❑ Standard City/Town Application Fee
2. Electrical ❑ Total Project Cost' (Item 6) s multiplier x -_
i. Plumbing S '. Other Fees: 5
4. Mechanical {HY'AC) .S List:
5. Mechanical (Fire
Su t cession) i Total All Fees: S
—� Check No. Check Amount _('.!,h Anw n t
0. Total Project Cost I 5 0 Paid in Full 0 Ou(stmding Balame
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (C•SI.1
Ll.cnsc Nunlhrr liy)u.0 wn D.ur
Name uI CSL- I luldcrl �[ I A _ Lul C'Si. f�� a Lrr hrluw 1
\Jdn. . �GO`K Desirl nio❑
II I l nn•slnned itil, In :k D IN Pt
Rewlc ted L@' f.tnull wrllclh inc —11
.11_n:uurc _-- VW �1 �1:I.onn Onls I
kC kemdrnual Kuolinc
fel:phone ld.nl ial \\,Idol, .md Sidw-
SF dennal Suhd Fuel Burlunc \ .j I'l i.ln._linl_ill ion ii
D Ro'Idenl l.d Demob I wo .�
5.2 Registered (Lome Im rocemenl Cuntractor (HIC)
I Regl uatlon Number
Ii IC Cum11rmy Name ar II Reeutranl Name -
ri Con
a Sit i e 14 V"A O MV5 I. � G �7
Add • ,
�"�/%3i Fxpoatiult Date
Signature Telephone
SECTION 6: WORKERS' CONIPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 2506))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure io pmudc
this affidavit will result in the denial of(he 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 properly hereby
authorize to act on my behalf. In :III matters
relative to wol k authorized by this building permit application.
_ — I
St nature of Owner Date
SECTION 7b: OWNERI OR AUTHORIZED AGENT DECLARATION
1, , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to (he best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Si ned under the am%and penalties of erju .) i
NOTES:
I. An Owner who obtains a building permit to du his/her own work,or an owner who hires an unreglslerad cun(ra�it,H
(nil registered in the Home Improvement Contractor (HIC) Program), will not have access to the ❑rhitra(io i
program or guaranty fund under M.G.L. c. 112A. Other important intlumanon on the HIC Program and
Construction Supervisor Licensing (CSL)can be found in 780 CMR Regulations I l0.R6 and 1 MAO. renpectllch
' When substantial •.v )rk is planned, provide the Information below:
To(al flours area (Sq. F(.I
(includmg garage. finished ba,enlent/atrlcs, decks ur pnrchl
Gross living area ISq. Ft.) Habitable room count _ --
Number of tlreplaces Number tit hedro,nns ----___--
Nunlber of ha(hnnuns Numbered halt/hash, _----------__- --
1 1'spe art healing system _ _ Number of deck,/ porchc,
Type tit ioollllg s1'slem _ Lll'b"ed _ Opcll
1. "Total Project Square footage" may be substituted tort 'Total Project C•o,(" ---~I