BPA-17-266 CA,�,
J
-1 fN/''iL C. 1, G
1911 APR 12 ID
The Commonwealth of Massachusetts
r —i- Board of Building Regulations and Standards CITY OF
SALEM
� r
Massachusetts State Building Code,780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For OfficiA Use Onl
Building Permit Number: Applied:
I
Building Official(Print Name) Signature v Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes no Map Number Parcel Number
13 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 Food Zone Information: 1.8 Sewage Disposal System:
�{ Public 0- Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
/A I-g-1,vcx 01i 7 ti Salem AAA,01 A 70
Name(Print) City,State,ZIP
3 F�rcx r S+ 603-807KV JSc��.Ott_K-1
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) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2: r nC 4C,11
f/. V .t// in i-.A: e 74/7e
e s•e, r,c , d f ''ho-) &,i/
SECTION 4:ESTIMATED CONSTRUCTION COST
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ .2;5gel00 1. Building Permit Fee:$ Indicate how fee is determined:
2 Electrical $ ❑Standard City/Town Application Fee
t a�' ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ ! t>vU 2. Other Fees: $
4.Mechanical (HVAC) $
List: cy
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 3.f,ETt ❑Paid in Full ❑Outstanding Balance Due:
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5.2 Reg�istcred Home Improvement Coutracter(HIC I
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own. Sbli:,/11'
sF.unas(,: l%`OgtkfRS'COMPLNSAI ION INSVRANCII: AFFIDAII'MALGA-c. 152). 41506)1
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lhi•j;iflidaxil wi-ll rrs;ilt in;he kirn-M"0'thr- ,he building Permit.
ned A, .Lv;t.Nmzhec1:.' . .......... Met..
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I-ECI](>,N -a:ONIVNER AUTHORIZATION TO BE COMPLETED WHEN.
AGENT OR CONTILWTOR APPLIES FOR BUILDING PFRMTT
1. w%I)wrerof he Nuble'.-A rmrIvrt%'%herrh-v aijftii/v
:,.i ;w,os: ri, m1f, In all mallian rt!l;i1jvt::to murk aathor./rd h" 1h;,; NJI&wr pkl,-M;t a"
J;caa on.
SECTION 7b:OWNEW ORAUTHORIZEDAGEN I DECLARA HON
By cntcr_'ri2 m-I. name Lxnh-,". I mefe.t- .1Lh2n%' ui:&'r Lhc paim wx! pcn;d!,e%(,fl'prrjkir%. th.^t alcif*tJhv inSmnaticm
1 is applicatic-1 If ErL)-Z Ill IhL bCNL(If IM k't1V0A'lC!9"vv M." tjngierti;;vi&niz.
"117
5.z):.,7(if'A tb Dale
NO*I'U%:
An 0,%j1ef who obtain&a tniliZI.m., er',o0v hires an urm-gistcrod contract,-T
NF-WI, h- h'�hcr owl wirk. DrAn 1),411
:tjII1 rvyi%rt:rcd In;hr l.imw ltriprovem"i Ckjn(rwuy7if1[C ?rvermi i.will not hay.-3cxx-m;ti)thz 3fh!'traCL'A-)I1
ptotmim(:,T 07tumin1% hind undeT MI.G.L. c 42A. C.1EK-r i liffifta,11' III fk:r-,I Ut;Ire.Off'fit:I:'A ft hr I
mformation c.xi thk:Cow:ruvliim Surwr-.1,141 I T I icenti-c.an be found 3-t
T. '%kLben substantial work is planmcrL pTovidc the infr.--rfnation
T otal fl cw)( alta i.;q.
(ml%" ;s6n??arra 1 41- I t :eMtzb-x roori count
N. 11mb,cri.-.`f;;rcPl&cfzs \UIr+-_-1 of hj_-J-%xm-v%
Pe t:l ht:alinv,,�%tcrr, Numbcr cf decks'porches
Tv r 1 o: im,u sy-mimn 0pal
Co%l-
',�)tal P-'j 'Spare x