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BPA-17-257 ` "L-z 1 The Commonwealth of Massachusetts a`R,,E �IC1ki�;L � 11F Board of Building Regulations and Standards SALEM Massachusetts State Building Code,780 CMR ZQl i APR ' ( Ae> r 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling J� This Section For Official Use Only Building Permit Number: Date pplied: Building Official(Print Name) Signature Dat SECTION 1:SITE INFORMATION 1.1 Pr perty Address: 1.2 Assessors Map&Parcel Numbers Z &f-I U m 5 r" 2 - 00S7-0 L'! L la Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.)1, Property Dimensions: 2 T�,G ,-4111�/- r U 2 6 Zoning District Proposed Use Lot Arka sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided / S 23 ' At /v 1C.7 Y-35-,4 3c) 1, it 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 91" Private❑ Zone: _ Outside Flood Zone? Municipal 0 On site disposal system ❑ Check if yesY SECTION 2: PROPERTY OWNERSHIP' 2.1 O err of Record- 4 e nt) City,State,ZIP � � !3�/=f�//►'1 5'i �/� -`>�l�-r°y-YI LF: J� -r. No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building Y Owner-Occupied ❑ Repairs(s) li� Alteration(s) lir I Addition Er" Demolition Accessory Bldg.❑ Number of Units Z- I Other ❑ Specify: Brief Description of Proposed Work : G v r f X r S 7-11V 6 T v✓0 r- IPI Y ZirU /(/CT 1Z/:- r /d 12 c- ri✓ a,,v v v L / r ' L SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only Labor and Materials 1.Building $ 2 GC O 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee $ 6 d b ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ j j o G 2. Other Fees: $ 4.Mechanical (HVAC) $ 2D 6100 List: 5.Mechanical (Fire $ ression � 'Total All Fees:$ heck No. Check Amount: Cash Amount: 6. tai Project Cost: $ ,j coo ❑Paid in Full ❑Outstanding Balance Due: o�o�l' Gqq C-OST bV- -r-(3`A11 �bT� LIJCI, DORA ,E-T-S) l SECTION 5: CONS'T'RUCTION SERVICES 5.1 onstruction Supervisor License(CSL) S l O ! - ! 6 GY /�g� �� /►/ License Number E.prat on Uate Name of CSL Holder T _ List CSL'fype(see below) Type. Description No.and Street U Unrestricted Buildin a to 35,000 cu. R. ter- /f L 1k,/J¢ C) l / U R Restricted 1&2 Family Dwelling City/ruwn,State,ZIP M Masonry RC Rooting Covering WS Window and Siding SF Solid Fuel Bunning Appliances &7;e %f/��9G.as I insulation Tele hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) /-96 3 ©EZ 3 f$ G �t ,=,R ,b'�;ZjV / G l"q K R'S 6U«"v HIC Registration Number E!cpir ion Date I IIC Company Name or HIC Registrant Name ` ✓L ��E/�i>.v S -;5 7 9C/if fo/14 57 G rs No.and Street Email address City/To nState ZIP Tele hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.15L¢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 Issuance of the building permit. Signed Affldavit Attached? Yes.......... No...........17 SECTION 7a-.OWNER AUTHORIZATION TO BE COMPLETED.WHEN.. OWNER'S AGENT OR CONTRACTOR APPLIES`FOR BUILDING.PER VIIT 1,as Owner of the subject property,hereby authorize - t9 act on my behalf,in all matters relative to work authorized by this build' g p mit plication. Al Print Owner' arae(Electro c Signature) ate SECTION 7b:OWt Rt 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 a plicatio is true andcurate tot est of my knowledge and understandin Print M3 ner's or Ant rized Agent' acne(Elec onic Signature) Date NOTES: I. An Owner who obtains a building permit to do his/her own work,or art owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will Lw 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 %v%vw.mass.cov:'oca Information on the Construction Supervisor License can be found at vv%vw.niass.,ov'dns . 2. When substantial work is planned,provide the information below: 'notal tloor area(sq. R.) _�(including garage,finished basement/attics,decks or porch) Gross living area(sq.tt.) 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. "rotal Project Square Footage"may be substituted for"Total Project Cost"