PER APP CAP UNUSED DOOR B17-47 s �
4 Z.CA�-
6
k The Commonwealth of Massachusetts CITY OF
i Board of Building Regulations and Standards SALEM
q Massachusetts State Building Code, 780 CMR Revised,blur 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
r This Section For Oficial Use Onl
Building Permit Number: Date.A lied:
(I
Building Official(Print Name). Signature Date
SECTION 1 SITE INFOItiNtATION.'
Property Address: 3g nriy^ l�\ 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street9 yes no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
"Luning District Proposed Use Lot Area(sq tt) Frontage(It)
1.3 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: 1.8 Sewage Disposal System:
Public❑ Private O Zone' — Outside Flood Zone? Municipal O On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHie
Owner r of Record:
t.LG 54(eNt,� /✓MPC 01,9 70
NN me(Print) City,State,ZIP
No.and Street Q Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction O Existing Building O Owner-Occupied O Repairs(s) ❑ 1 Alterntion(s) O Addition O
Demolition ❑ Accessory Bldg.O Number of Units Other O Specify:
Brief Description of Proposed Work':
SECTION 4:ESTINIATED CONSTRUCTION COSTS
Itcm Estimated Costs: OfQcial Use Only
Labor and Materials)
1. Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard CiVrgwn Application Fee
2. Electrical S
O Total Project Costs(item 6)x multiplier x
3.Plumbing -S 2. Other Fees: S
►.,XIcchanical (I-IVAQ S List:
S.\fee hanical (Fire S
Su ressiun) "focal All Fees:S
Check No. Check Amount: Cash Amount:
G.Total I'rnjret Cost: O Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License( SL)
License Number Expiration Date
V Name of CSL Holder
I t ' s [` List CSL'rype(see below)
�,,fr 7
No.;md Street Type Description
S't's U Unrestricted(Buildings up to 35,000 cu. ft.
R Restricted 1&2 Runily Dwelling
City/town,State,ZIP M 1%4asonry
RC Rootinit Covering
WS Window and Siding
.Y' '31-I Z 35't l SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered dome Improvement Contractor(NIC)
FIIC Registration Number Expiration Date
I IIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /Town State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G L.c.152.4 2SC(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 Ishuance of the building permit.
Signed Affidavit Attached? Yes..........0 No...........❑
SECTION 7a:OWNER AUTHORIZATION.TO BE COMPLETED WHEN.,
OWNER'S AGENT OR CONTRACTOK APPL IES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize Co-r`t o
t9 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
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 Owner's or Authorized Agent's Name(Electronic Signature) Date
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(HIC)Program),will Lro have access to the arbitration
program or guaranty fund under INI.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.u()v!oca Information on the Construction Supervisor License can be found at 4v�rw.ma+s.�ov!dns
2. 1Vhen substantial work is planned,provide the information below:
"notal tloor area(sq. ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. 13.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half%batlu
Type of heating system Number of decks/porches
'type of cooling system inclosed Open
L1. "Total Project Square Footage"may be,ubstitutcd for"rut i Project Cost"