57 WARREN STREET, 2 BPA 17-95 INSULATION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
4 Massachusetts State Building Code, 730 CMR SALEM
Revised:Nur 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling "?
This Section For Oficial Use biry
/ Building Permit Number: Data A t d: `
P)
Building OtTcial(Print Name). Signature Date
\ SECTION t SITE INFORMATION (t .
i
LI Property Address: 1.2 Assessors,Xlap&Parcel Numbers
1.la Is this an accepted street?yes no heap Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions: '
Zoning District Proposed Use Lot Area(sq 11) F take(tt)
1.3 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Nater Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Public O Private O — Check if esD Municipal O On site disposal system O
SECTION2: PROPERTY OWNERSHIP!`
2.1 Ow r of Record:
�. , o a n rr, •
RoutS S'u l��,
�1me(Print) City,State,ZIP
Gtr Sf. Gly- 3/9-797'
No.and Street Telephone Email Address
SECTION 3:DESCRIPT ON OF PROPOSED WORK=(check all that apply)
New Construction O Existing Building O Owner-Occupied O Repairs(s) D A .tion(s) O Addition O
Demolition O Accessory Bldg.D Nutttber of Units Other pecify: �Sirla�ir�..
Brief Description of Proposed W k':
SECTION a:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OfBciul Use Only
Labor and Arterials)
1 Buildin; S I. Building Permit Fee:S Indicate how fee is determined:
0 Standard City/Town Application Fee
2.Electrical S
O Total Project Cost(Item 6)x multiplier x
3.Plumbing S 2. Other Fees: S
4.Mechanical (HVAC) S List:
5. \lechanieal (Fire S Total All Fees:S
Su ressiun)
Check No./3100 Check Amount: Cash Amount:
G.Tuhtl Project Oust.]S 36rM - D Paid in Full D Outstanding Balance Due:
1NS�q�
SECTION 5: CONSTRUCTION SERVICES ,
5.1 Construction Supervisor License(CSL) l of 7 -7 61
LicenseNmu—ber Expiration Date
Name of CSL Holder List CSL'fype(see below)--y_—
FriC TYpe Description
No—Ind Street 3 Hilton St U Unrestricted [3uildin aP to 35,000 cu.ft.
Salem MA 01970 R Restricted 1&2 Family Dwelling
Ni %4asonry
City/fown,State,ZIP RC Roolin Coverm
WS Window and Sidin
SF Solid Fuel Burning Appliances
I Insulation
`77 D Email address D Demolition
Telephone y�
5.2 Registered d '��ome Improvement Contractor(HIC) o / 3 r Z
Atlantic Weatherization,LLC HIC Registration Number Expiration Date
l 11C Company Names RIQ itue
Email address
Nu.and Street
Ci /Town State ZIP Tel one
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152.$23C(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.......... No...........0
SECTION 7n:OWNER AUTHQRIZATION TO BE COMPLETED.W HEN>
OWNER'S AGENT ORC014TRACTORa1PPLIESFOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
1:9 act on my behalf,in all matters ative to work authorized by this building permit application.
Date
Print Uwncr's Name(Electronic Signature)
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 thi pplication is trueAd accurate to the best of my knowledge and understanding.
` .
Date
Print owner's or Authorized Agent's Narne(Elluctronic Signature)
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(EIIC)Program),will nu have access to the arbitration
program or guaranty fund under 1M.G.L.c. 142A.Other important information on the HIC Program can be found at
%vww m•u;L:ov!oca Information on the Construction Supervisor License can be found at w��ns
2. 1Vlien substantial work is pLarmed,provide the information below:
total floor area anti R.) (including garage,finished basement/attics,decks or porch)
Habitable room count
Gross living area(sq.tt.)
Number of bedrooms
Number of fireplaces
Number of hal6baths
Number of bathrooms Number of decks/porches
type of heating system Enclosed Open
"type of cooling system
1. "Total Project Square Footage"may be substituted for"Total Project Cost"