0013 PRESTON ROAD BPA-17-151 Z_2- Z
i
The Commonwealth of Massachusetts ' !Pi;, a
Board of Building Regulations and Standards CITY OF
W
SALEM
Massachusetts State Building Code, 780 CN11, MAR — A lysed,61ur 2011
L® Building Permit Application To Construct, Repair, Renovate Or Demolish a [`1
O One-or Tivo-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name). Signature Date
SECTION 1:SITE INFORMATION'
1.1 Prope r Address: 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes % no Map Number Parcel Number
1.3 'Lotting Information: 1.4 Property Dimensions:
"Luning District Proposed Use Lot Area(sq ft) Frontage(It)
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 C3
Check if yes13
SECTION2: PROPERTY OWNERSHIP
2.1_9wne
�me(Print l SC City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) Addition O
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': 7TOA3W '
SECTION a: EST1bIATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials)
I Building 3 1. Building Permit Fee:S Indicate how fee is determined:
D Standard City/Town Application Fee
2. Electrical S 2 ❑Total Project Cost(item 6)x multiplier x
3. Plumbing 2. Other Fees: S
=1.`(cchanical (FIVAC) S List:
5.,\lechanical (Fire S Total All Fees:S
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: 'S �� ❑Paid in Full 0 Outstanding Balance Due:
g l v jL—nz— T
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
ry�n/1�o r,� Q License Number Expiration Date
Name oCCSL Holder List CSL'rype(see below)
Ty Description
N ;aid S eet U Unrestricted BuilJin s u to 33,000 cu. tt.
R Restricted 1&2 F:unil e Dwellin
cityil���t,State,ZIP M Masonry
RC Roofinst Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
S3�2L �. CH ttS, �G I Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) /6<—//,^ 3
HICi tt'q jlumber Expiration Date
HI IC Cump;uty Name or 11[C Registrant Name No.and Street J Email address`
Ci /Town State ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.$2SC(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 IsAtiance of the building permit.
Signed Affidavit Attached? Yes ..........t7 No•.......•••�
SECTION 7a:OWNER AUTHORIZATION.TO BE COMPLETED WHEN.
OWNER'S AGENT OR CONTRACTOR APPLIESFOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize -
t9 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:OWNEW 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 this application is we and accurate to the best of my knowledge and understanding.
,et W4
Pint Owner's or Aut torize Agent's Name(Electronic Signature) Date
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 nut 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.,ov:'oca Information on the Construction Supervisor License can be found at www.mass.(ov u1)s
2. When substantial work is planned,provide the information below:
'notal door area(sq. ft.) (including garage,finished basement/attics,decks or porch)
area(sq.ft.
Gross living ) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
'rype of cooling system Enclosed Open
3. "-notal Project Square Foota;e"may be substituted for"Total Project Cost"