BPA-17-153 KITCHEN REMODEL +
The Commonwealth of Massachuse .07 1N; j
Board of Building Regulations and Standards
CITY OF
Massachusetts State Building Code, g SALEM
"4 .. Revised Mar 1011
Building Permit Application To Construct,Repair, Renovate Or Deo
Ali
I One-or Two-Family Dwelling
`�► % This Section For Official Use Only
Building Permit Number: Dat pplied:
b 4uo Z4��
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
L l a Is this an accepted street?yes 1/1� no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) 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? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑ p p y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
i'V-1(3 a ` C,o i?A' - ,
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) arl Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2:
rr iltVi s
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building ( �,' � M �,�; 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ l3,c)k_� ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 1 -1 G j?, ,: 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ b ? ❑Paid in Full ❑Outstanding Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(RIC) r +
y-, r HIC Registration Number Ei:piraiion Date
HIC Company Name or HIC Registrant Nam
off',(�!✓ °.>+ti t:�_] C;_ I i' �- .��'}'+t` 63
No.and Street ' Email address
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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... CX' No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize w L r--�/1 r-
to act on my behalf,in all matters relative to work autho by this building permit application.
Print OwnWs Name(Electronic Signa e) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of petjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,fmished 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"