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BUILDING PERMIT APP The Commonwealth of Massachusetts 1 %liii"+i �€ `. ' Board of Building Regulations and Standards SALEM# Massachusetts State Building Code,780 CMR SALEM ZQ{l APR ReRe&,+8011 Building Permit Application To Construct,Repair,Renovate Or Demolish a F. One-or Two-Family Dwelling �. This Section For Official Use Only A , Building Permit Number: Date Ap i d: �- Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1 1.1 Pro a ddress p 1.2 Assessors Map&Parcel Numbers 20 .�1►sl.. SSI . 1.1 a Is this an accepted street?yes no 14ap 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 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: Public I�r Private❑ Zone: _ Outside Flood Zone? Municipal ff On site disposal system ❑ Check if yes❑ QQ SECTION 2: PROPERTY OWNERS IIP' 2.1.Qw�erl o C1. -11+1 W..I,e.,�. 1" A 6-44-68 rr-Name(Printp City,State,ZIP n I I Fe�v;c� Ic-c�...� 61-1-z9r- SSl ��1.r-1�•.��o CA"^CQ%1-K t No.and Street Telephone Email Ad ress SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply) New Construction❑ Existing Building Owner-Occupied Wf Repairs(s) ❑ Alteration(s) 511 Addition ❑ Demolition e Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify: Brief Description of Proposed Work2: r SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ ZS'dpV 1. Building Permit Fee:$ d: Indicate how fee is determine 2.Electrical $ zoo* ❑Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ S—Z)1 2. Other Fees: $ K=�Z 4.Mechanical (HVAC) $ (J-760 List: 5.Mechanical (Fire $ Total All Fees:$ Suppression) Check No. Cheek Amount:TCash Amount: 6.Total Project Cost: $ 369 ❑Paid in Full ❑Outstanding Balance Due: rnfa � ��r, T-D G .C. �f- SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 0'44 2t ' ®r, l�L�t k� >1�L License Number En Date Name of CSL[folder List CSL Type(see below) Type Description No.and Street AM U Unrestricted(Buildings a to 33,000 Cu. ft. SA-L6lf AM ©�CI �� R Restricted 1&2 Family Dwelling Cityfrown,State,ZIP M Masonry RC Roolinst Coverin WS Window and Siding SF Solid Fuel Burning Appliances y lL� 3�2 lid —J-4 G hyo 45'�,457, ly4 - 1 Insulation Tele hone Email address D Demolition 5.2 Inc istered Home Improvement Contractor(HIC) HIC Registration Number ExIfiration Date FITC Company Name or H1,V Registrant Name No.anda W/ Email address Ci /Town State,ZIP Telephone SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.4 2$C(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 uuilding permit. Signed Affidavit Attached? Yes..........❑ No...........O SECTION 7a:OWNER AUTHORIZ IMON.TO BE COMPLETED.WHEN: OWNER'S AGENT OR CONTRACTOR APPLIESFOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorizeG ( 1✓nc-�- - I act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 71b:OWNERr OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information fain , Alication is tr and accurate to the best of my knowledge and understanding. Print Owner' r Authorized Age 's Name(Electronic Signature) Date NOTES: I. An Owner who obtains a bVilding 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 nu 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 %vw%v.mass.gov'oca Information on the Construction Supervisor License can be found at%v%Nw.mass.1ovAIJ)s 2. When substantial work is planned,provide the information below: 'notal floor area(sq. ft.) (including garage,finished basementlattics,decks or porch) Gross living area(sq. ft.) Habitable room count Number of fireplaces O Number of bedrooms 2 Number of bathrooms Z Number of hal0baths 'type of heating system Number of decks/porches 'fype of cooling system Enclosed Open 1 "Total Project Square Footage"may be substituted for"total Project Cost"