0013.5 MEADOW ST BPA-17-176 FIRE DAMAGE Lt rl
f The Commonwealth orf Massachusetts
Board of Building Regulations and St dar CITY OF
y�ly� Massachusetts State Buildijil( W70CM SALEM
Revised Mar 2011
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 pplied:
Building Official(Print Name) Signature V Date
1 SECTION l:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
13 s` erel�6o> S/
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 tt) 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:
Zone: Outside Flood Zone?
Public❑ Private❑ Municipal❑ On site disposal system ❑
Check if ves❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Own`eer'of Record-
Z!-
ecor ;
ame(Pant) V
NCity,State,ZIP —'
/S". _ 47rC11A11�_1�_ %y_?5?2,1-P?Y4 7 N
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑�JNumber
wner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ of Units Other ❑ Specify:
Brief Description of Propos d Work`':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials) _
1. Building $ G'p C 1. Building Permit Fee:$_ __Indicate how fee is determined:
2. Electrical $
❑Standard City/Town Application Fee❑Total Project Costs(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire I $ Total All Fees: $
Suppression)
--- —
Check No. _Check Amount: Cash Amount:
6.Total Project Cost: $ 7 �� 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
i 5.1 Construction Supervisor License(CSL) 7� / / 7
4-WW k.2,"", z;-)3.yam .C R' License Number Expiratio )ate
Name of CSL Holder
/� � List CSL Type(see below)
I/{ iv
No.and Street Tye Description
G, Unrestricted(Buildings up to 35,000 cu.ft.)
14--e �� d� / ®— R Restricted 1&2 Family Dwelling
City�/T vn,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
4(� 5 AP C d�. SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
/� C ." �'- c�p,✓ �� HIC Registration Number Ex7ira'on Date
HTCompany Name or HIC Registrant Name
an��d Street � Email address
� 0/ 9 7,'/ 7y
Ci /Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.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 Nsuance 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
1,as Owner of the subject property,hereby authorize
to/lact on my behal,f,,in all matters relative to work authorized by this building permit application.
tvl
Print Owner's Name(Electronic nature) lbate
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,l hereby 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 knowledge and understanding.
Print wner's or Auth9ent' . m5WTectrofiic Signature) ate
_ NOTES:
I. 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. og vloca Information on the Construction Supervisor License can be found at wwvw.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor 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"maybe substituted for"Total Project Cost"