PER APP REMODEL 2ND FL BATH & BEDRM 17-45 The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY SALEM
Wit
Massachusetts State Building Code, 780 CbIR d Alar
L� I. Revised,L/sir 20//
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
t This Section For Official Use Only_
Building Permit Number: Da pplied:
Building Official(Print Name). Signature Date
SECTION l:SITE INFORMATION
LI Pro erty d es : 1.2 Assessors Map&Parcel Numbers
1.la Is this an accepted street9 yes no Mop Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
"Zoning District Proposed Use Lot Area(sq 11) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Nater Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.S Sewage Disposal System:
Zone: Outside Flood Zone?
Public❑ Private❑ ` Check if es❑ Municipal❑ Onsite disposal system ❑
SECTION 2: PROPERTY OWNERSHW
Owner of Record:
me(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alterntion(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Itcim Estimated Costs: Official Use Only
Labor and Materials)
I BuildingS I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/fown Application Fee
2. Electrical 5
❑Total Project Cost((tem 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. XIcchanical (FIVAC) S List:
5.Mechanical (Fire � Total All Fees:S
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: 'S 2— ��, ❑Paid in Full O Outstanding Balance Due:
f 2q Matt-v-p 7t7 � • L �
SECTION 5: CONSTRUCTION SERVICES
5.Instruction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
/ List CSL Type(see below)
t4
No.:uid Street Type Description
)4 �t� 6��ZQ U Unrestricted(Buildingsu to 35,000 cu. ft.)
l R Restricted 1&2 Family Dwelling
Cityffown,State,ZIP M tNaso
RC Rooting Coverinst
WS Window and Siding
1Fl� SF Solid Fuel Burning Appliances
l 6 �C�ofl t iL I Insulation
Telephone Email address D Demolition
5.2 Registered [Lome Improvement Contractor(}I IC) MV2b s
e 14-z TY ��c �e`s b— HIC Registration Number Expi/rution Date
I II Cum N e or 11IRegi Mme rem
_- (,--) t/llZ
N t orlnlr� j 1 Email aJ ress
ti/Town, State ZIP Telephone l�
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.g 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 Is!u a of the building permit.
Signed Affidavit Attached? Yes ..........❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION.TO BE COMPLETED.WHEN.,
OWNER'S AGENT Olt CONTRACTOR APPLIES FOR BUILDING PERMIT[,as Owner of the subject property,hereby authorize f1w,'v41-12l _
tg act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW ORAUTHORIZED AGENT DECLARATION
tcn my name below,I hereby attest under the pains and penalties of perjury that all of the information
n this application is true and accurate to the bestof my knowledge and understanding.
s or Authorized Agent's Name(Electronic Signature) Date
NOTES:
ner who obtains a building permit to do his/her own work,or art owner who hires an unregistered contractor
istered in the Home Improvement Contractor(HIC)Program),will Leo have access to the arbitration
m orGuaranty fund under NLG.L.c. 142A.Other important information on the H(C Program can be fount at
ass.eov!oca Information on the Construction Supervisor License can be found at www.mass.,ovhbs
2. When substantial work is planned,provide the information below:
'fotal tloor area(sq. ft.) (including garage,finished basementlattics,decks or porch)
Gross living area(sq.11.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
'fype of heating system Number of decks/porches
'fype of cooling system Enclosed Open
1. "Total Project Square Footage"may be substituted for"Total Project Cost"