0004 KELLEY ROAD 2_`i Z
i
The Commonwealth of Massachusetts
';' E Board of Building Regulations and Standards CITY OF
Massachusetts State Buildinf?Code, 780 CMR SALEM
Revised Mai-2011
O i Building Permit Application To Construct,Repair.Renovate Or Demolish a
One-or Two-Family Dtivelling ;
This Section For Official Use Only' ( L i t,
Building Permit'Number: DaEe Applied:
l
Buffdmg Official(Print Name)
t Signature
SECTION 1:SITE INFORMATION
Ca 1.1 Property Address: ! 1.2 Assessors Map&c Parcel Numbers
l.la Is chis an accepted street?yes v" no iviap Number Parcel Number
1.3 Zoning Information: 1 4 Property Dimensions:
Zoning District Proposed Use I Lot Area(sq ft) Frontage(8)
1.5 Building Setbacks(ft)
Front Yard ' Side Yards Rear Yard
Required Provided Required ( Provided Required Provided
{
1.6 Water Supply.(vLG.L c.40,g 54) � 1.7 Flood Zone Info ation: i 1.8 Sewage Di osal System:
i Public� Private❑ Zone: _ Out ' e Flood Zone? I
eek ifyes❑ + Municipal On sire disposal system ❑
SECTION 2: PROPERTY 0WINERSHIPt
2.I Owner t of Record: �
I �Rr77- Carr , �i•�>'rw+ If C/ jG�
Name(Punt)
II ,�i City,State,ZIP 14
No.and
Telephone Email Address
SECTION 3:DESCRIPTIO)!OF PROPOSED WORK' (check all that apply)
flew Construction❑ I Existins Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
i Demolition L1. I Accessory Bldg.❑ I Number of Units Other ❑ Specif;,:
B of escri n of Proposed Work'-: -
r
r.."'GAG 7G 7 c
SECTION 4:ESTEVLATED CONSTRUCT-TON COSTS
Item I Estimated Costs:
(Labor and Materials) I Official Use Only
1_Buildin`
1 5 y�, �,�; . t. Building Permit Fee:S Indicate how fee is determined: i
r 2.Electrical S I ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing
i S / l��� L� 2. Other Fees: S
4.ivlechanical (HVAC) I S List: i
5.Mechanical (Fire
Suppression) 1 S Total All Fees:S
6.Total Project Cost:
Check No. Check Amount: Cash Amount:
I S L Z d in Full ❑ Outstanding Balance Due:
PL)-T
(NA(),I L_ 3 to l-1
SECTION 5: CONSTRUCTION SERVICES f
5.1 Construction Supervisor License(CSL)
0-21-91
Name t' y License Number Expiration Date
of CSL Holder
Ii!q -e`�r y /� List CSL Typc(see below) LA
No.an Street / Type estricted(BDescription
�z'�� ,,� �� / U nr
Uuildings u to 35,
._ 000
CiWTown,State,ZIP ! R ( Restricted I&2 Family Dwelling
\lasonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Buminekpplianccs
I1 insulation
Telephone Email address i D Demolition
52 Registered Home Improvement Contractor(HIC) 1
l�i-,� .✓ LLd-+$���Y+d � rt✓
HIC Com anv,Jame or HIC Registrant�rrant'Name
Registration`cumber Expiration Date
No andStreet
j Lf=,_ /IA ,$ E1�� �� Jre� Ll %'L � Email address
Ct /Totitm.State,ZIP !l Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.;.c.152,§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide j
this affidavit will result in the denial of the Issuance of the building permit.
I Signed Affidavit Attached? Yes ----------❑ No p
i SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWN'ER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I.as Owner of the subject property,hereby authorize Z� � i�"
to act on my behalf,in all matters relative to work authorized by this building permit application.
; Print Owner's Name(Electronic Signature) Date
SECTION[7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By enrerina rnv name 6efow,r Increby attest under the pains and penalties of perjury that all of the information
contained in this application is-true and accurate to the best of my know:ledge and understanding.
I�
Print Owners or Authorized Agent's wine(Electronic Signature) Date
NOTES_
1. An Owner who obtains a building permit to do his;her own work,or an o-vtmer who hires an unregistered contractor
(not registered in the Home improvement Contractor(HIC)Program),MH not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A_Other ii-nporrant infotmarion on the HIC PIO dM can be IOund at
Information on the Construction Supervisor License can be found
2. tiTi hen substantial work is planned;provide the information below:
Total floor area(sq.ft.) (including garage,Finished basementlattics,decks or porch)
Gross living area(sq. tt_) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Nlumber 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"