B-17-69 REROOF002 .� The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 730 CNIR Revised,thir 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
1 One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name). Signature Date
SECTION 1:SITE INFORMATION
I.I Proer Address: 1.2 Assessors Map&Parcel Numbers
J �� h'
- e'
I.1 a Is this an accepted street?yes 'A no Nlap Number Parcel Number
1.3 'Zoning Information: I'4 Property Dimensions:
`Luning District Propose Use Lot Area(sq 11) Frontage(It)
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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑ y
SECTION 2: PROPERTY OWNERSHIP
2.1 Owner of Record:
NN me(Print)�– City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building�l Owner-Occupied J;(I Repairs(s) go Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': ' .-2 x?
7�z 16
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials)
I. Building ( �� Chi 1. Building Permit Fee:$ Indicate how fee is detennined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost(Item 6)x multiplier x
3. Plumbing `; 2. Other Fees: S
4.Mechanical (11VAC) S List:
5.Mechanical (Fire Total All Fees:S
Suppression)
Check No. Check Amount; Cash Amount:
6. Total Project Cost: ❑Paid in Full O Outstanding Balance Due:
Sbu3
_;5i_5UD 7D 4!'_'C44A.Avr���i �' �Cyt 3
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
' License Number Expiration Date
Name of CSL Holder List CSL'Pype(see below)
57Type
Description
No.;md StreetU Unrestricted 13uildin a to 35,000 cu. tt.
�fa/i/✓�/'f l�j� 4�9/h 3 R Restricted 1&2 F,unily Dwelling
Cityfrown,State,ZIP M Masonry
C RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
' 2>1_�,,zs j 1 Insulation
Telephone Email address D Demolition
"21gtstered Home Improvement Contractor(HIC) 9 :2-1 �
IXC le.V�c�� (1. A,'��y HIC Registration Number Expiration Date
I lir rymp Name or IIIC Re,& t Name
5 Email address
N0. 1d Street
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 Is§uance of the building permit.
Signed Affidavit Attached? Yes ...... No...........0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN,
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize ,,' /I ,z -
t9 act on my behalf,in all matters relative to work authorized by this building p6rmit application.
Print Owner's Name(Electronic Signature) Date
SECTION 71b: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.
✓�',�2,��, <e _J/ / - "�-oat' -,2
Print Owner's or-Authorized Agent's ame(Electronic Si afore)
NOTES:
I. An Owner who obtains a building permit to Jo his/her own work,or an owner who hires an unregistered contractor
(not-registered in the Home Improvement Contractor(HIC)Program),will got have access to the arbitration
proram or guaranty fund under NI.G.L.c. I42A.Other important information on the HIC Program can be found at
\«vw masS.eoV.!oca Information on the Construction Supervisor License can be found at%v\v%v.masj.tov'dos
2. When substantial work is planned,provide the information below:
'notal floor area(sq. ft.) (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
'fype of heating system Number of decks/porches
I ype of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"