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BPA-17-268 3t otz M The Commonwealth of Massachusetts SALEM Board of Building Regulations and St ibI N Al. �'` CITY OF Massachusetts State Building Code,780 CMR ' Revised Mar 2011 Building Permit Application To Construct,Repair,Rq�*#R r em611s��a 5 One-or Two-Family Dwelling ` This Section For Official Use Only Building Permit Number: Da Applied: Building Official(Print Name) Signature e SECTION 1:SITE INFORMATION 1.1 Propej dT 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted street?yes no Map 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❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSIHP' 2.1Owner'of Record: 11 0`k cj o� 01�+71f�c., Slew M�� t�1 G`7C, Name(Print) I City,State,ZIP '33 - �c�c_•�or No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alterati qs Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of UnitsOther 9 'Specify: Brief Description of Proposed Work2: 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: ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ A 4.Mechanical (HV C) $ List: 5.Mechanical (Fire $ Total All Fees:$ Suppression) �� Check No. Check Amount: Cash Amount: 6.Total Project Cost: Ls ❑Paid in Full ❑Outstanding Balance Due: FYI t4) Lk C\ OM_ 4 l ) q SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) c6 -©y 5ygz 61-11 -2D19, L �C(�"L1 c�r' License Number�r Expiration Date NamesofCCSL Holder List CSL Type(see below) t� No.and Street „ l T Description L N / �� ,, O Unrestricted(Buildings u to 35,000 cu.ft. �U �4D R Restricted 1&2 Family Dwelling Cityown,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 151 2/3 013 I Insulation Telephone mail addres( D I Demolition 5.2 Registered Home Improvement Contractor(HIC) L 16!Z522 ��hpp /� CoVi sKUG i , ,nCIL , k7c HIC Registration Number Expiration Date HIC Conirmy Name or IRF Registrant Name g mar ST / ,.log r113ya fmd-GSI No.and Street Email address zkr �g o/%oti ��a� Ci /Town,State Z .— 17�— Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.GJL 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..........❑ 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 ro r- G� Arc 1.2' (�v�c� Cu- -1� to act on behalf in all matters relative to work authorized by this building permit application. Prin er'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 thi Ii tion is true and accurate to the best of my knowledge and understanding. Print Owners or Authorized Agent's Name(Electronic Signature) Date NOTES: 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 www.mass. o�v/oca Information on the Construction Supervisor License can be found at www.mass. ov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of halFbaths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage'maybe substituted for"Total Project Cost"