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The Commonwealth of Massachusetts ; 4 rn
<j tk Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
_ Revised Mor 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
l Building Permit"u her: Date Applied:
Building Officia (Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
o �i - lac
l.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required =rovided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Lone: Outside Flood"Lone?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownerdary 15rodanas Salem MA 01970
Name(Print) City,State,ZIP
30 sable rd 9787895785 Legerm@comcast.net
No.and Street 'Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Constructi Existing Building❑ 1 Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units Other ❑ Specify:
Briefes ription of Proposed Work'`: ^
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SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1.Building $ 11 L( Z:> S' 1. Building Permit Fee:$ _Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ �J' t �� . ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees:$
C� Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ •��� ❑paid in Full 10 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) r
� -
� � License Number Expiration I ate
(� List CSL Type(see below)
No.aStreet {� Type Description
j U Unrestricted(Buildings up to 35.000 cu.ft.)
trid R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Tele hone J^ Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) W6 J t 1 S �I 'Q
St EIIC Reggistr'attiion Number E piratioLn?Date
HIC Company Na r F1IC Itistrant Nam
0-1 No.and Street �f r1� n ^� Email address
' au
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 Issuance of the building permit.
Signed Affidavit Attached? Yes ........ rr' No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUI�LnDING PERMIT
1,as Owner of the subject property,hereby authorize I b u))A -� r
to act on my behalf,in all matters relative to work auth i d by this building permit application.
Gary Prodanas 1.17 ��' 2/3/17
Print Owner's Name(Iiiectronic 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
contained in this application is true and accurate to the best of my knowledge and understanding.
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Upene � � -0Print O er s or AuthorizeilAgent' 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 not 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.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of Freplaces _ 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"