BPA 17-238 SINGLE STORY ADDITION The Commonwealth of Massachusetts E ,�
CITY OF
Board of Building Regulations andiSiiiM d3ONAL jx $ � �. SALEM
• 00Massachusetts State Building Code, 780 CMR Revised Mar 2011
J Building Permit Application To Construct,Repair,AhMg aJ)eJ;blQ&
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date p lied:
Building Official(Print Name) Signature 1VDate
SECTION 1: SITE INFORMATION
(� 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
6p,.4or 9-f_4p 't M 3% t,,t /8
1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
A'-J reC65ef �n i
Zoning District Proposed Use Lot Area(sq ft) Frontage(fl)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
/ 1Z.9 3Sv 35,5 ,
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone? Municipal`'''g p
On site disposal stem 11Public� Private❑ Check if yeses
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
N,e v%r u 4�D ( SD1n.n�C r`�C.rt LE r1 /y'�� MName(Print) City,State,ZIP QY��cl i y��-b S3—q L(G O
2-9 �Ilzor 2> 93a' 59y 9LGS Jc�AS nip L�
No.and Street Telephone Email Ad ess
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Constructio Existing Building 0' Owner-Occupied la Repairs(s) ❑ Alteration(s) Additio
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2:
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SECTION 4:ESTIMATED CONSTRUCTION COSTS [ —2 OF I
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ i D 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Costa(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: $ �!�3�' � ❑Paid in Full ❑Outstanding Balance Due:
Lf [ 0 LA v
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
�s- 1(05'03 yy-�1
'PE%�f., ii--) W I. L.(^ `G) )( License Number ExpirationDa etet
Name of CSL Holder� LA,
CSL Type(see below)
'�f �� ` — Type Description
No.and Street
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town.Statt,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
��Z> ���� G/���«k �!/�Yii��GC ✓�� I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street V Eriveril address
Ci /Town,State,ZIP Tele hone
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 ..........0 No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
-- OA/ ReiUAL r AC co N714.eTv
1,as Owner of the subject property,hereby authorize (` W l 6D
to act on my behalf,in all matters elative to work authorized by this building permit application.
2'7 zv 177
nt Owner's e(Electronic Si nat re) _ ate
v t G A I L so Kusa n� N �..
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 th' pplication is true and ccurate to the best of my knowledge and understanding. /
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rint Owner' or Authorized Agent's Name(Electro Scnetro ignature) -1 Date
t l 0
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
1.vww.1nass.g0v/e>ca Information on the Construction Supervisor License can be found at www.mass.gov%dt)s
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) ( L 4�7D (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) l G �;U Habitable room count 7
Number of fireplaces __ Number of bedrooms 2—
Number of bathrooms ' / _ Number of half/baths /
Type of heating system — Jrr.1 Number of decks/porches
Type of cooling system J '�KcCC` Enclosed Open /
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
UJ
Assessor's Map 31
Assessor's Map 31 Lot 191
Iron Rod
Lot 192 (set)
70' Assessor's Map 31
Iron Rod Lot 189
(set)
w
LOT "F" "n w
6,659 S.F.f o?
0
N
PROPOSED 12.9' _ _ o
ADDITION
C01r^
CA ~` Assessor's Map 31
I ? crag
O ,
_ Lot 188
Stake/Nail
Stake/Nail / (set)
(set) 6.7' 6.9'
Assessor's Map 31 Wood
Lot 186 P Dwelling
0
w-11 "'-
U
r..a
V'
q 60.0' Drill Hole in Sidewalk
(set)
Drill Hole in Sidewalk
(set)
OF MgSS
DAVID PL 0 T PLAN OF LAND
o` s
PHILIP
TERENZONI SALEM, MA.
� N
No. 38720 PREPARED FOR:
FESS°�Pv GAIL JOHNSON
29 GRANT ROAD
SCALE:1"=20' DATE: SEPTEMBER 19, 2016
Zoning District: R-1 DAVID P. TERENZONI, P.L.S.
Deed Reference: Book 33961, Page 244 4 ALLEN ROAD, PEABODY, MA. 01960
Assessor's Map 31, Lot 187
Existing Lot Coverage = 16.7% t
Proposed Lot Coverage = 22.8% t
S16-020
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Assessor's Map 31
Assessor's Map 31 Lot 191
Lot 192 Iron Rod
(set)
70 Assessor's Map 31
Iron Rod Lot 189
(set)
w
LOT "F" C w
6,659 S.F.f U'-
o
N
PROPOSED 12.9 o
ADDITION
o
� V% (� crag Assessor's Map 31
0 `t Lot 188
pAeA"r Stake/Nail Stake/Nail(set)
2 )b '(I a�?S'eQ4l 6.7' 6.9'
Assessors Map 31 / Wood
Lot 186 P Dwelling
J1
Cp
Li 0 S1� 60'0 Drill Hole in Sidewalk
(set)
w�
'WA 4�t ba.Jf-- Drill Hole in Sidewalk
(set)
(,�•..J2 Z 1�.c� .
OF "gs`S9
p<«„� DAVID Sys PL 0 T PLAN OF LAND
PHILIP
TERENZONI SALEM, MA.
Lcc.GC. � ��„
�+�...Q No. 38720 PREPARED FOR:ESSN
L : GAIL JOHNSON
�/F 629 GRANT ROAD
q t S bS 3 9�6o SCALE:1"=20' DATE: SEPTEMBER 19, 2016
Zoning District: R-1 DAVID P. TERENZONI, P.L.S.
Deed Reference: Book 33961, Page 244
Assessor's Map 31, Lot 187 4 ALLEN ROAD, PEABODY, MA. 01960
Existing Lot Coverage = 16.7% t
Proposed Lot Coverage 22.8% t
S16-020