22 BERTUCCIO AVE - BPA-11-605 l a The Commonwealth of Massachusetts CITY
Board of Building Regulations and Standards OF SALEM
p Massachusetts State Building Code, 730 CMR. 7"edition HewsedJaumarv,
11hn+1 Building Permit Application To Construct, Repair, Renovate Or Demolish a /• =r/ux
ur Two-Family wel inn
This Section F O(licial Use Onl
Building Permit Number: Date Applied:
Signature:
Building C m ssiane/ n• •tor of Buildings Date
SECTION 1:SITE INFORMA ION
I.yfpWd drtals: O n 1.2 Assessors Map& Parcel Numbers
L la Is this an accepted street'?yes_ no Map Number Parcel Number
,t 1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Arca(sq 11) Frontage(Il)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided ElffTEProvided
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 E3 On site disposal system 13Public O Private O Check if es❑ P
SECTION 2: PROPERTYOWNERSHIPt
--------------
Aci
tt f Rec rd: B G0(-i ZZ IOer-tV CG tt U . ( Z
) Address for Service:
M X153 Z7` 6
'telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials
I. 1luilding S 1• Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2, Electrical S ❑Total Project Costs(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S Total All Fees: 5
Su ression
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S paid in Full ❑Outstanding Balance Due:
I
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Dale
Nance of CSI.-I lolder
List CSL 7)pe(see below)
Address MDRiesidential
Description
Unrestricted u to 35.000 Cu.Ft.)
Signature Restricted IRr2 FamilyDwellin
Masonry Only
Residential RoofingC'ovcrin
Telephone Residential Window and Siding
esidential Solid Fuel Burning Appliance Installation
Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or IIIC Registrant Name Registration Number
Address
Expiration Date )
Signature 'telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.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 Issuance of the building permit.
Signed Affidavit Attached? Yes.......... 0 No...........0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S GENT OR C NTRA TOR APPLIES FOR BUILDING PERMIT
• ( Gv 06 "� ,o as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative oMoriz by thiAlildingperryttapplicatip,,)
II
$I• ata t �/ Z�/I 1
Dale
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1• as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.115, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Ilabilable 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 he substituted for"Total Project Cost"