1-3 SALTONSTALL PARKWAY - BPA- 799-10a The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, T"edition
OF SALEM
Revised Jantsury
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 Applied:
a I
Signature:
S /
v J v
Building Commissioner/Ins for of Buildings Date
SECTION 1:SITE INFORMATION
LI Property Address: 1.2 Assessors Map& Parcel Numbers
L I 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 R) Frontage(R)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public Private Check if yesCl
Municipal On site disposal system
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ovv 1{egbrd:
p U
D —
J 5171 cis 5
Name(Print) Address for Service:
21
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction Existing Building Owner-Occupied Repairs(s) 01 Alteration(s) Addition
Demolition Accessory Bldg. Number of Units_ Other Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:
Official Use OnlyLaborandMaterials
1. Building S 1 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 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S
Paid in Full Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(( SL) 4 4,L
ri i/
7 U .-/ S7 6,-- Licensle Number Expiration Date
Name of CSL- I lulder
L L eeListCSL"type(s below)_
f DescriptionA7,di U Unrestricted(up to 35.000 Cu.Ft.
R Restricted Ik2 Famil Dwellin
ligna use J j M Masoroy Only
Cr RC Residential Rooting Covering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered H rr0 C11 antractor(I ICGG
Regisuatio Number
fIIC Comp•a or f IC Re8ist nt Nan `
fir e vz"L IJ
Address 7y fS'' 3 1 Exp lion ale
Signature relephone
J
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 4 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 o.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
1 r Q as Owner of the subject property hereby
authorize i'r to act on my behalf, in all matters
relative to work authorized by this building permit application.
S ignature of Owner Date
SECTION 7b:OWN/ERI OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
the statements and information on the fgregoing application are We and accurate,to the best of my knowledge and
behalf.
j/ 5
Print Name
Signature of Owner or uthorized Agent Date
Signed under the pains and nalties of 'u
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 Mol have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program andConstructionSupervisorLicensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I I O.R5,respectively.
2 When substantial work is planned,provide the information 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"