17 ARTHUR ST - BPA-16-1122 ROOFING c-K It
The Commonwealth of Massachusetts CITY OF
( Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised.Nur 1011
_ Building Permit Application To Construct, Repair, Renovate Or Demolish at
t
One-or Two-Family Dwelling
e This Section For Official Use Onl
Building Permit Number: Date Aplied:
1'1 1 Building Official(Print Name). _ , Signature-: . . Date
Lo
SECTION 1:SITE INFORiv1AT10N
1.1 Property Address: 1.1 Assessors Afap&Parcel Numbers m M
I.I a Is this an acce ted street9 yes_ no Map Number Parcel Number w
1.3 •Zoning Information: 1.4 Property Dimensions: A ,
Zoning District Proposed Use Lot Arca(sq tt) Frontage(It) Qp
1.5 Building Setbacks(R) *'
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 13 On site disposal system 13Public❑ Private 13 Check:if yesCI
SECT[ONZ: PROPERTYOWNERSHIP":
Il 2.1 Ownert of Record: A
o_Y L A c S City,State,ZIP r
iT�me(Print)
7 1-) i r.J,� s—f— �O 1 t�3�f C/t�
No.and Street Telep one Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that upply)
New Construction❑ Existing Buildinnner-Occupie Repairs(s Altemtion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. mber of Units_ Other ❑ Specily:
Brief Description of Proposed Work': O 7TH D
IRo o�c TR.is CD >
SECTION 4: ESTIb1ATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and M1laterials)
1. Building S 7 0 Oo 0 1. Building Permit Fee:5 Indicate how fee is determined:
❑Standard Citylfown Application Fee
2. Electrical S ❑Total Project Cost'(hem 6)x multiplier x
3. Plumbing S 2�pther Fees: S
d.Mechanical (FIVAC) S - List:
5.Mechanical (Fire S Total All Fees:S
Su ression)
/ p d Check No._Check Amount: Cash Amount:
G.'futal Project Cust S tc�s�Q _ CO3 Paid in Full 13 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) Cr 4--(63
Tleo�rJ i%v+ f License Number Expiration Date �l
Name of CSL Mulder
List CSL'Type(see below)
�—'�j 2� a.�C ✓.� S T Type - Description .
No. and Street -
`J .�(� U Unrestricted(Buildings tip-to 35,000 cu. It.
t��7Q b2 c, Y 1 '.4 � A `'1 6-0 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Rooting Covering
WS Window and Sidins
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5,2, Registered Home Improvement^Contractor(HIC) -Z_✓''
6�c �)—Y C T J, y— HX Registration Number Expiration Date
HI_C Cmnpmy e or[it C Re rstrant Name
1
4�Street ✓ D Email address
Ci rrown State ZIP _ Telephone
SECTION 6:WORKERS'.C0M1IPENSATION INSURANCE AFFIDAVIT(M.G,C: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 Isluance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No...........C3
SECTION 7aa OWNER AUTHORIZATION,TOBECOMPLETED WHEN; ;
OWNER'S AGENT OR CONTRACTOR 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) Dale
SECTION 7b:OWNEW ORAUTIIORIZED AGENT DECLARATION
Dy entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's u i ulhorized Agent 'Namc(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 no have access to the arbitration
program or guaranty fund under LI.G.L.c. 142A.Other important information on the HIC Program can be found at
tew.v.mass.eov�'oca Information on the Construction Supervisor License can be found at wtrw.masssov:'.hts
2. When substantial work is planned,provide the information below:
'rota) floor area(sq. R.) '� ,(including garage,finished basement/attics,decks or porch)
Gross living area(sq. R.) Habitable room coma
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number otdecks/porches
Type of cooling system Enclosed Open
3. `"Total Project Square Footage'may be substituted lar"Total Project Cost"