B-17-37 t2
(� -Z� The Commonwealth of Massachusetts '4 cl� 43 CITY OF
Board of Building Regulations and Standards SALEM
w ,
Massachusetts State Building Code,780 CMR
Revised;t-far20/!
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Da Applied:
> l yll
Building Oficial(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
ICU. ___ r_1r1- -- -
l.la Is this an accepted street? -y_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(K)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.U.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
i y Zone: Outside Flood`Lone'?
Public❑ Private❑ Check ifyes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 O er'of Rec :
George Knowlton Salem MA 01979
Name(Print) City,State,ZIP
106 Loring Ave 9785678763 Rogsnrse55@yahoo.com
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Constructiowzr� Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ I Accessory Bldg.❑ Number of Units Other ❑ Specify:_ _____
Brief esvripnon of Proposed Work2: Q ��+� l - n 1
SECTION 4:ESTIMATED CONSTRUCTION COSTS 1
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $11800 1. Building Permit Fee:$ _Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $� ��Z ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $,__._-___.__-._.
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ ------- -- —--------------- _
Suppression) Total All Fees: $—___,_____.
O heck No. _____Check Amount: Cash Amount: __
6.Total Project Cost: $ '� ❑ Paid in Full ❑Outstanding Balance Due:
r1fi:QVQn CN
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) r r
license Number Expiration I ate
NalW t f' ", der
I , # List CSL Type(see below)
---- -- —
No.a trees Type Description
r ' jm V U Unrestricted(Buildings up to 35.000 cu.ft.)
- � R Restricted 1&2 Family Dwelling
City7rown.State,/IP M Masonry
RC Roofing Covering
_._. — _ _----___--_---_-----.-----__ ._- WS Window and Siding
Solid Fuel Burning Appliances
-1p 1.1 ((011 I Insulation
Telephone I-;mail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
t!_....__----- ____ ____-______ IIIC Registration Numbcr Gxpirauon Date
I{1C Company Nat r.111C R q istrant Num
No.and Street --� .�L. .:C..�-.S._�7�E��,
)+ ` Email address
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 ........ 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 authorizeto act on my behalf,in all matters relative to work authorized by this building permit application.
George Knowlton )Y f 11/3/16 _
Print Owner's Name(Eat
lectronic Signure_) 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
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owerizeds or AuthorAgent' Name(Electronic Signature) D to
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 HIC Program can be found at
www.mass,gwlpca Information on the Construction Supervisor License can be found at www,mass.eov_;dps
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.It) Habitable room count
Number of fireplaces dumber 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"