0006 GALLOWS HILL ROAD - BPA-17-180 The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
WJIM
Massachusetts State Building Code,780 CMR Revised,blur 2011
6p Building Permit Application To Construct, Repair, Renovate Or Demolish,a
One-or Avo-Family Dwelling
r This Section For Oficial Use Only t i-i ir x
�- Date A id
Building Permit Number:
.;
Building Ofticial(Print Name). Signature Date— t :
SECTION 1:SITE INFORNIATI61W
corm.
1.1 Property Arddres S / /( 1.2 Assessors�Nlap&Parcel Numbers
r+�
r , 7 4'
1.In Is this an accepted street? es no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions.-;'
Zoning District Proposed Use Lot Area(sq ft) nta e( )
1.3 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Su I •(M.G.L C.40, 54 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
PP y. § )
Zone: _ Outside Flood Zone? Municipal O On site disposal system 13Public❑ Private O Check if yesQ
SECTION 2: PROPERTY OWNERSHIP'`
2.1 Owner'of Recor • I-,"
• Ar �l l�City,State,ZIP
�1me( 'int
g- /(Z Email AddressNo.and Street Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
jDemolitioEnEC03
w ConExisting Building❑ Owner-Occupied ❑ Repairs(s) ❑ AI eration(s) ❑ Addition ❑
Accessory Bldg.❑ Number of Units Other pecify:
Brief Description of Proposed Work':
G
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and lklaterials)
1'-- I. Building Permit Fee:S Indicate how fee is determined
I. Building $ :
❑Standard CitylTown Application Fee
2.Electrical S ❑Total Project Costs(item 6)x multiplier x
3.Plumbing S 2. Other Fees: $
4.Mechanical (FIVAC) S List:
5.iMechanical (Fire "total All Fees:S
Su ressiun) Clieck No.L JACheck Amount: Cash Amount:
i
6.'Iota) Project Cost: /�) 13i i% - Paid in Full ❑Outstanding Balance Due:
`5(Z-71 M(a��.C-_V -rb N7 - U319-Ak:,yt Z fa-ncrl
SECTION 5: CONSTRUCTION SERVICES
-------------------
5.1 Construction Supervisor License(CSL) $ 7 q7 7 App
License Number tion Date
Name of CSL[folder List CSL Typo(see below) (_A-
Eric W. Palm
Type Description
on
No.amd Street "InSalem, " 01970 U Unrestricted Buildin u to 35,000 cu. ft.
R Restricted 18c2 Famil Dwellin
City/fo+vn,State,Z1P ,%,I Masonry
RC Roofinit Covering
WS Window and Sidin
q SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
Atlantic Weather'nition,LILT NIC Registration Number Expiration Date
[IIC Company rf n'RoNSrSOast J01daee
No.and Street Sidemg MA 01970 Email address
Ci /Town State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(nG,L.c.M g 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 IsAuanc f the building permit
Signed Affidavit Attached? Yes.......... No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED.WHEN.*
OWNER'S AGENT OR COkTRA&01t APPLIES FOR BUILDING PERMIT
1,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,1 hereby,attest under the pains and penalties of perjury that all of the information
contained' tills:-application i true and accurate to the best of my knowledge and understanding.
�3
Print Owner's or Authorized 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(MIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at
+e+v+v.m:u,.eov!oca Information on the Construction Supervisor License can be found at+v+v+v.ma s.�ov!dns
2.--When work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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 substihded for"Tutai Project Cost"