BPA 17-237 The Commonwealth of Massachusetts
Board of Building Regulations and Standards
CITY OF
Massachusetts State Building Code,780 All: f '
��R _4 iSALEM
sed Mar 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Appl' .
0 A� ��� z1414-7
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
f1 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1� 1.1a Is this an accepted treet?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) 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❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Sos(n Ca' rr���� S�rltm m� oIq-70
Name(Print) City,State,ZIP
a2!
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2: 1
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ A G ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
-ictmrchi n License Number Expiration Date O
Name of CSL Hbld6r
+,�„G �� ' List CSL Type(see below)
Ila
9�i f 1( Y'
No.and Street r 'f Type Description
1 m, I k� M Ak �I� U Unrestricted $uildin s u to 35,000 cu.ft.
1 � R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
0:5e 0 h76 M C4 l C HIC Regtstration umber Expiration Date
I-IIC Comp Nam or HIC Legis t^Name
No. Street g Email address
NMI, 61q
Ci /Town,State,ZIPS 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 ..........I} No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'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 ap 'cation is true and accurate to the best of my knowledge and understanding.
Print Owner' or Authorize Agent's Name(Electronic Signature) D to
NOTES:
1. Am 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 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. "Total Project Square Footage"may be substituted for"Total Project Cost"
f CITY OF SM.E. . N'LkSSACHUSETTS
• BUELDIING DEPiR-nMNT
WN
130 W.ASHLNGTON STREET,Yo FLOOR
TM (978)745-9595
FAX(978)740-9846
KIINiBERLEY DRISCOL L
MAYORTHoai�+s ST.PLERR,&
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG COMMMIONER
Workers' Compensation insurance Affidavit: Builders/ContractorsJElectricians/Plumbers
Anolicant Information /Please Print Legibly
Name(Busines&Orpnizatiotvindividuap:�rn�Y 1 C4✓� Lf Y l Q (�1�S�1'UC�"(Gs✓�
Address: I I QG CAt- 1 (d0LO—A
City/State/zip: :H��
Are you an employer?Check the appropriate box: Type of project(required):
1.&1 am a employer with 4. ❑ 1 am a general contractor and 1 6. Q New construction
employees(full and/or part-tune).' have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in an capecitY• workers'comp.insurance. q
❑Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.(:1 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers' 13.0
comp.insurance required.]
Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
t t lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mast submit a new affidavit indicating Such.
:ContrauYots that check this box must attached an additional sheet showing the name of the ntbtonttacbrs and their workers'camp.policy informatiom.
fain an employer that it providing workers'compensation Insurance for my employees. Below Is the policy and fab sho
information.
Insurance Company Name: 446 no e V
Policy 4 or Sclf--ins.Lie.#:�a�C�^ U U'SG 1 3Q o,�t; �- ,_ Expiration Date: i
Job Site Address: la lin eU,�. City/State/Zip:y I®�1 mA 019
Attach a copy of the workerscompensation policy declaration page(showing the policy number and expiration date).
Failure to wcyre coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a
finc up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under t pains and penalties of perjury that the information provided above is true and correct
= t r Date:
Phone#: " g�K— _76a
Ojjcial use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/i.icense#
Issuing Authority(circle one):
1.Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other ..___
Contact Person: ______ ____�_- Phone#: