BPA-17-167 FINISH BASEMENT • UY/ •1I/. 7 7
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 730 CMR Revised,Nur 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Oficial Use Only
Building Permit Number: Date liedt =3 tS
Si afore Date
_ Building Official(Print Name) P�
l SECTION 1:SITE INFORMATION'
LI Property Address: �S 1.2 Assessors:Nap 8c Parcel Numbers
la�N t�-�GG
I.la Is this an accepted street?yes 110 Map Number Parcel Number
1.3 'Lotting Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq t1) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
1.6 Water upply:(M.G.L c.d0,§5d) 1.7 Flood Zone Information: 1.8 Sewage D osal System:
Zone: _ Outside Flood Zone? Municipal On site disposal system [3Public Private❑ Check if yes13
SECTION 2: PROPERTY OWNERSHM'
2.1 Ow pert 2.LR S, rd:mac.�K S41f Nt
i��me(Print) City,State,ZIP
Telephone Email Address
No.wind Street
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ OwnerEof
upied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ NumbeUnits Other ❑ Specify:
Brief Description of Proposed Work': 44
A,NS wr
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Offlcirl Use Only
It¢m Labor and Materials)
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cose(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
=1.Mechanical (I-IVAC) S List:
5. ,Mechanical (Fire Total All Fees:S
Suppression)
�Cl�ieckNo. Check f\mount: Cash�\mount:6.Total Project Cost: S �2Full D Outstandin;Balance Due:
Jj 1 to M :s t L--%,EV
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License,(CSL) V %O S 3 Z(.
J ��/'n SKorsl� License Numbe
Expiration ate
Name of CS.THolder List CSL'fype(see below) "
0- Z0C q
Type Description
No.and Street
���� MA- !� Z3 U Unrestricted(Buildings u to 35,000 w. it.
R Restricted 1&2 Family Dwelling
City/town,State,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
r SF Solid Fuel Burning Appliances
`?bs-94Z--3141J.5 KA Mu K#Ct (,-)V*A I Insulation
Telephone Email address D Demolition
5.2 Itegistered Home Improv
ement Contfactor(HIC) 11406
3 x I
DS �'f�,ICbMwr�l HIC lVegistration Number Expiration bate
HIC Cu tpany N e or HIC Registrant Name
O, !26 200 StKd Itwr114�;) 6-Mkt(. ci
No.and Street)9owgr t .56e-Na 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 Is§uance of the building permit.
Signed Affidavit Attached? Yes .......... No...........17
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 -
t4 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 tr a an accurate to the best of my knowledge and understanding.
Print Owers u Authorized Agents Name(Electronic Signature) DAt
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(111C)Program),will nut have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the H[C Program can be found at
www.mass.gov'oca Information on the Construction Supervisor License can be found at vvww.ntas.sov'dns
'-T 1Vhen substantial work is planned,provide the information below:
Total floor area(sq. R.) (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 ofcooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"