PER APP INSULATION B-17-53 The Commonwealth of Massachusetts rs IPV
Board of Building Regulations and Standards Zt?�i ��k z CITY OF
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Massachusetts State Building Code, 780 CINIR p
Revis ,ti i 20/l
Building Permit Application To Construct, Repair, Renovate Or Demolish a
V ' One-or Two-Family Dwelling
i This Section For Oficial Use Only
Building Permit Number: Date pplieds
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORiNATION'
LI Prorty Address* 1.2 Assessors,Nlap qtr Parcel Numbers
1.la Is this an accepted street. yes Ko [slap Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft) `
Front Yard Side Yams 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Chuck if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.t Onerc of Rec d: S�+ P.-,
/e
of nem
1N'me(Print) City,State,ZIP
yg 6 L-4, -• F-5-7-
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alterntion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other a-Tpecify:
Brief Descrip of of Proposed Work':
SECTION 4:ESTI,NIATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1. Buildin; 1. Building Permit Fee:S Indicate how fee is determined:
[3 Standard City/'Town Application Fee
2. Electrical S ❑Total Project Cost(item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4.Mcclumic:al (HVAC) S List:
5.Mechanical (Fire S
Suppression) "total All Fees:S
Check No.L3_aTheck Amount: Cash \mount:
6. Total Project Cost: S 0 Paid in Full 0 Outstandin; Balance Due:
SECTIONS: CONS'T'RUCTION SERVICES
5.1 Construction Supervisor License(CSL) O 7' -7-7 tf' Z.3
License Number Expiration Date
Name of CSL Holder
Eric W. Palm List CSL Type(see below) 1A
No.and Street3 Hilton St Type Description
Salem, MA 01970 U Unrestricted(Buildings tip to 35,000 cu.11.
R Restricted 1&2 Family Dwelling
City/town,State,ZIP M �blason
RC Roolinst Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
9717614- 91 q 3 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) I que cl, 3117-11g,
Atlantic Weathedgation,LLC HIC Registration Number Expiration Date
I IIC CompoyRIM1% Wi Name
No.and Stree eMi NU OD70 Email address
Ci /Town State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.1 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 Is§uance of the building permit.
Signed Affidavit Attached? Yes.......... No...........l7
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 Cr-G ?a 61-1 _
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(ElectroffmSignat 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
contait#in this applicatigs true and accurate to the best of my knowledge and understanding.
t
/ /1-7
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 nut have access to the arbitration
program or guaranty fund under NI.G.L.c. I42A.Other important information on the HIC Program can be found at
www.mass.cov:'oca Information on the Construction Supervisor License can be found at www.mas,.�ov'd�s
2. When substantial work is planned,provide the information below:
total floor area(sq. R.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number 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"