B-17-87 INSULATION . P�iL ' ,�
The Commonwealth of Massachusetts
M Board of Building Regulations and Standards Z ,� '�T SALEM
I q / Massachusetts State Building Code,780 CMR Revised thir2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
a One-or Tivo-Family Dtivelling
1 This Section For Official Use Onl . .: i It 4A
Building Permit Number. Date App Ik&
- 1(r
Building Official(Print Name). Signature Date
SECTION 1:SITE INFORMATION'
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
� e u Y
1.1 a Is this an accepted str et?yes no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimenslons: ;k:.
Zoning District Proposed Use Lot Area(sq If) Fron age(tt)'
1.3 Building Setbacks(R)
Front Yard Side Yards Rear Yana
Required Provided Required Provided Required Provided
1.6 Nater Supply:(tv1.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system C3Public❑ Private❑ Check if yeso
SECTION 2: PROPERTY OWNERSHIP!`
2.1 Q Vnertof Record: �� s'I
Ora .R /L�`/
lwsme(Print) City,State,ZIP
.6 3dk-o?6q- /5r1 Z
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED wORW(check all that apply)
New Construction❑ Existing Building 13 Owner-Occupied ❑ Repairs(s) O Tlte ion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other pecify:
Brief Descriptionof Proposed Work":
14-4
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Of(tcial Use Only
Item Labor and jklaterials)
I. Building 1. Building Permit Fee:S Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical S ❑Total Project Cost'((tem 6)x multiplier x
3.Plumbing S 2. Other Fees: S � rr�
4..Mechanical (I•IVAC) S List:
5.,Mechanical (Fire S 'rotal All Fees:3-
Suppression)
Su ression)
Check No.J jA�U_Check Amount; Cash Amount:
6.Total Project Cost: .5 ❑Paid in Full D Outstanding Balance Due:
2- 1 l -7 Mai t-� Tb C--1-C- I IV sf--)SE;
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) $-7! 7"7 3
License Number Expiration Date
Nance of CSL 1loldeiErlc W. Palm List CSL Type(sec below)
3 Hilton St Description
Type P..
To.:uid Street Salemq MA U, U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwellin
City/town,State,ZIP �%A %Iasonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
q-7k- 7YY- S'/ 4 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) r gzoo
_ Atlantic West1. '..Alma LLC', FITC Registration Number Expiration Date
tlIC CompanVIRTA 6M me
No.and Street Salem,MA 01970 Email address
Ci frown 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 Issuance of the building permit.
Signed Affidavit Attached? Yes.......... No...........l7
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED.WHEN.
OWNER'S AGENT OR CONTRACTOR APPLIES'FFOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize �►^� G I ��'� -
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Xlr .c. Z
Print wncr's Name n lec ignature) 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 pis application is t e and accurate to the best of my knowledge and understanding.
Print Owner's ur Authorized Agent's Name Electronic Signature) Date
NOTES:
1. 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 Lout have access to the arbitration
program or guaranty fund under NI.G.L.c. 142A.Other important information on the HIC Program can be found at
Ny%v%v.m .eo
as, r:'oca information on the Construction Supervisor License can be found at
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basementlattics,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. -'notal Project Square Foota;e"may be substituted for"fatal Project Cost"