PER APP KITCHEN REMODEL B17-54 'rhe Commonwealth of iVlassachusetts
�
WBoard of BuilJing Regulations and Standards CITY OF
SALEM
Massachusetts State Building Code, 730 CMR Revised,Nur 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
t One-or Tivo-Fcunily Dwelling
f� This Section For Official Use Only
Building Permit Number. Date:Applied, zj 411
L1
Building Official(Print Name). SignatureDate
SECTION it SITE'INFORNIATIOPU
LI faroperty 1.2 Assessors N[Ap 8r Parcel Numbers Mp
I.Ia Is this an accepted-7 street?yes no btap Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
"Luning District Proposed Use Lot Area(sq tt) Frontage(R)
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: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: Outside Flood Zone? Municipal❑ On site disposal system ❑
Click if es❑
SECTION 2: PROPERTY OWNERSHIP-
2.1 Olynerl of Record: �
A60�� ���,� _ VX19
�11�m�rmt) City,State,ZIP
Q Lz N e
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED 1VORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alterntion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units I Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTINIATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Nlaterials
I Building S 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical S 2 All ❑Total Project Cost(Item 6)x multiplier x
3. Plumbing 13 2. Other Fees: S
q..".lcchmical (FIVAC) S List:
S.Mechanical (Fire �
Suppression) "total All Fees:S
Check No. Check Amount: Cash Amount:
6.Total Project Cost: L
13Paid in Full 13 Outstandin; Balance Due:
I ( L+{ �rang—�.'1� -m N• C� ,
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
N;une of CSL Holder
List CSL'fype(see below)
No.iurd Street Type Description
U Unrestricted(Buildings up to 35,000 cu. It.
R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP L*VI lVasonry
RC Roolinst Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home mprovement Contractor(HIC)
d HIC Registration Number Expiration Date
I IIC omp ame r HIC Registran N. e
No.and Street o Email address
CityfTown Sta a IPele hone
4
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.ISZ.¢ 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 Istuance of the building permit.
Signed Affidavit Attached? Yes ..........O No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED.WHEN.
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERAIIT
1,as Owner of the subject property,hereby authorize _
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nene(Electronic Signature) 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
contai in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Age s N•me(Electronic Signature) ate
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/lot 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.m;►Ss.eov:'oca Information on the Construction Supervisor License can be found at w+v%v.mas.,rov'dns
2. When substantial work is planned,provide the information below:
'dotal floor area(sq. R.) (including garage,finished basemendattics,decks or porch)
(iross 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 I'or'Total Project Cost"