BPA-17-183 r
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'I'he Comniona,ealtlt ofi4assaehusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEMW Revised iblar 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Tito-Family Duelling
This Section For Otlicial Use Only
Building PermitNumber: i Date p ied:
_^ l Building 011icial(Print Name) Signature Dnte
`. •� SECTION 1:SITE INFORMATION
l 1.1 Property Address: %Pa V, D 1.2 Assessors Map & Parcel Numbers
i.[a Is this an accepted street?yes no Alap Number Parcel Number
�I 1.3 Zoning Information: 1.4 Property Dimensions:
i Zoning District Proposed Use Lot Ares(sq ft) Frontage(R)
1.5 Building Setbacks(ft)
I-ront Yard Side Yards Rearl'ard
Required Provided Required Provided Required Provided
I
1.6 Nater Supply:(A4.G.L c.40,§54) 1.7 Flood zone Information: 1.8 Sewage Disposal System:
' Zone: Outside Flood Zone?
Public❑ Private❑ 1 iCheck if yes❑ Municipal EJ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 O« r'of Reco-0#Lc ti /
\fame(Print) City,State,ZIP
1 5 ,� 4d, ��p 7kd
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED' ' RK`(check all that apply)
i New Construction❑ Existing Building 34 Owner-Occupied orl Repairs(s) ❑ T Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other O Specify:
Brief Description of ProposeWo k N he., rzlor
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials) i
1.Building $ 1. $ullding Permit Fee:S Indicate how fee is determined-
0 Standard Clty/Town Application Fee
2.Electrical $ []Total Project Costa(item 6)x multiplier_x
;.Plumbing $ 2, Other Fees: S
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire S Total All Fees:$ '
Suppression)
Check No. Check Amount: Cash Amount:
6.Total P roj ect Cost: S c7 ❑paid In pull ❑Outstanding Balance Due:
,�,x- A
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) Gz'7'/„(j�
Mid �, tni License Number Expiration Date
Name ofG'St bolder � )
�� ��ill �� list CSL Type(sec below)— t/
No.and Street Type Description
I (t l_ � i � 0 f1 } l t!� U Unrestricted(Buildingsu to 35,000 cu.ti.)
Ut * R Restricted 1&2 Family Dwelling
Cityrrown,State,ZIT' M Masonry
RC Roofing Covering
WS Window and Siding
SI' Solid uFuel Burning Appliances
Insulation
nsulation
Telephone Email address D Demolition
5.2 Re jt
tered Horne(Improvement Contractor(HIC) /N bt 0 3 1/7
y ��
agc G HIC Registration Number Expiration 9
t�ionrtDat_e
HIC C, an Name or HIC Rc strant Name
� r
No.y d 5trcM r Email address
01
�} I
Ci /Town,State,ZIP Tcle hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.In§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 ..........❑ No...........0
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 /Pja h1 Jt111
to act on my, half,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AVV40RAGENT DECLARATION
By entering my name below,I hereby attest under a pal an pe Ities of perjury that all of the information
contained in this application is true and accurate to e b of y owledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Sign Date
NOTESt
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(NIC)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
%vww.mass.1;avtoca Information on the Construction Supervisor License can be found at wwrv.macs.wvtdns
2. When substantial work is planned,provide the infbtmatlon 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"may be substituted fbr"Total Project Cost"