1D SPRUANCE WAY BPA 10-999CVo
The Commonwealth of Massachusetts
i Board of Building Regulations and Standards CITY
g r°Massachusetts Stat H4 mg Code, 780 CMR, 7'"edition
OF SALEM
7 Revised Junu vur
Building Permit App cation To Construct, Repair, Renovate Or Demolish a
4 1 One for Two-Fomily Dwelling
This Section For Official Use Only
Building Permit tuber: Date Applied:
Signature:
Building Commis i r/Ins for of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
I.l 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 It) Frontage(It)
1.5 Building Setbacks(it)
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 es
SECTION 2: PROPERTY OWNERSHIP'
Record:
Name(Prj t) Address for Service:
041 asp- 9i5'-az 9
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction Existing Building Owner-Occupied Repairs(s) 1 Alteration(s) Addition
Demolition Accessory Bldg. Number of Units_ I Other Specify:
Brief Description of Proposed Work':EtLZ- WC0 Ana i 6 inN'rb
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
OMclal Use OnlyLaborandMaterials
I. Building S I. building Permit Fee:S Indicate how fee is determined:
2.Electrical S Standard City/Town Application Fee
Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (FIVAC) S List:
5. Mechanical (Fire
Su ression
S Total All Fees: S
6. Total Project Cost: S 34 c,
Check No. Check Amount: Cash Amount:
Jvr-' 63 0 Paid in Full 0 Outstanding Balance Due:
1
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Con truction Supervisor(CSL)
pp L/d
v C 5 era 4 License Number IixpiAEmtionI ate
Name ol'CSL• I lolder List CSL Type(see below) LA
6L4 / s.,Z_ ,} DM1 tn5-er /
f Description
ress U unrestricted(up to 35,000 Cu.Ft.
R Restricted 182 FamilyDwelling
Signature M Mason Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or HIC Registrant Name
Registration Number
Address Expiration Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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...........0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, A- em 4 l2 /l e-l-I'h t as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to work utho 'this building permit application.
C, X lD /' • C7
Si azure o Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I, t M A y(e A ('6-,C/ /-h as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
I os-c nu e rn r Yh
Print Name 16
Signature ofO brAuthorized Agent Date
7
Signed under the pains and penalties of du
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 ConVactor(HIC)Program),will gQs have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be und in 0 CMR Regulations 110.R6 and I IO.RS,respectively.
2 When substantial work is planned,provide the inffo 7Rormation below:
Total floors 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"