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I s.s' NO. 256 5-�
J CONDOMINIUM 3
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NO. 251
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:2�1 file Commonwealth of Massachusetts , y
Board of t3uilding Regulations and Standards CITY
t'\ OF SALEM
Massachusetts State Building Code, 730 CMR, 7"edition
Revived Atturary
Building Permit Application To Construct,Re pair, Renovate Or Demolish a 1. '6uX
One-or Tit-o-Fun v DI•ellirr
This cc to or Of a e ly
Building Permit Number: X!ebV
Signature: ' l
ludding Commis4oner/ •tororl3uild gs Date
SECTION I:SITE INFORMATION
1,1 Property Address: // 1.2 Assessors Map& Parcel Numbers
I.1a 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(sy 11) 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 Zone'?
Public❑ Private❑ Check iryes❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: /�
datnry r/6 2. (5 G Z6cS6-k- (S�.6Fi� 4ai6-�
Name Pnnt) Address for Service:
g If-- 7g l7(r0
Si utu "Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': u-&p .i
/ rr .✓ aG� I Ior✓N w
6 cz
�o
SECTION 4: ESTIMATED CONSTRUCTION COSTS i
Item Estimated Costs: Official Use Only
(Labor and Materials
1. Building $ 1. Building Permit Fee:S Indicate how fie is determined:
�. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)s multiplier s
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S a 1 7 `,/� ❑Paid in Full ❑Outstanding Balance Due:
s
i '
(� SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
ke" Z, "a �+��, License Number Expiration Date
Name of CSI:I lulder
_ O I.ist C51.Type(see below)
/,ey
Address KC4. . Is. Description
ll I Unrestricted up to 35.000 Cu.FI.
It. I Restricted I&2 Family Dwelling
Sigma e A slasonry Only
er7r,no R ' Residential Rooting Covering
Telephone Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
U Residential Demolition
5.2 )tegistered Homeq Improvement Contractor(HIC) /yD eSdO
OnACon67 /. d tip
1IIC Company Name or IIIC Registrant Name Registration Number
ieo FrrAyCr�Y� k� vAa_ .46r� /a/a a/�di3—
AJdr• s �,
1w.s.. 9787P0-V( Expiration Dale
SLLn ure 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 ' he building permit.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
n
I, . /c G41 It(/ �Od C/Q as Owner of the subject property hereby
authorize ()ZSxC6cS to act on my behalf, in all matters
relative to work out arized by t 1 ut ding permit application.
S' • ore of wner Date
SEC//T//ION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
I, )—aVKb6 (1th^/"LOIv /�r717/(��'A�P`�Alas 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. ^ Nth
Print N ( v J
Sign a of Owner or Authorized Agent Date
Si ned under the pains and penalties ofperjury)
NOTES:
I. An Owner who obtains a building permit to Jo his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(IIIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations 110.116 and 110.115,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Ilabilable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number ofhalf/baths
Type of heating system Number of decks/porches
Type of cooling system (inclosed Open
J. "Total Project Square Footage"may he substituted for"Total Project Cost" 3 qd 'e90