31 BOW ST - BPA-16-923 KITCHEN 52-7z I v
The Commonwealth of Massachusetts
:, �Y 1 OF
Board of Building Regulations and Stand azds SALEM
WMassachusetts State Building Code,780 CMR Mar Mar 2011
Building Permit Application To Construct,Repair,Renoval:M AAA
XtAA arp
N One-or Two-Family Dwelling
T> S„cr43onFrxO ois1;tsa
n Building Permit,Number- Date Appli®ei:,
t ung OiScial(Prim e) SiBeahtre -
((�J SECTION l_:SITE$+i1 ORM 9 TION
L1 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
l.la Is this an accepted street?yes_)(_ no Map N.ber Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq fq Frontage(f t)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54)
17 Flood Zone Information: 1.8 Sewage Disposal System:
Public Cl Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es❑
SIPMON2: FR ERTYOWNERSRIP'
2.1 Owner'ofR Ord: C�I � A OIC-U
���ih5 -
Name(Print) City State,ZIP
lz ,a -4. 78- 7(ao•zzz2 (�•� '�yS X892 ��dnar •Cvr
No.and Street Telephone Email Address
SECTION&IIESCRIPTION OF PROPOSED WOR10(Oheck all that apply)
New Constructio2103i�st�g Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑Demolition ssory Bldg.❑ Number of Units_ Other ❑ Specify:BriefDescriptiond WorkZ: (.U¢� -
I ,ate I , PUIJ Q .t-,
Ce
SECTION 4:ESTIl1tATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Estimated
and Materials
1.Building $ 2 v 1. Building Permit Pee:$ Indicate how fee is determined,-
O Standard City/Town Application Fee
2.Electrical $ t7 Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 'O 2. Other Fees: S
4.Mechanical (HVAC) $
List:
5.Mechanical (Fire $ Total All Fees:$
X
Suppression)
Check No. (Steck Amount.. Cash ptnrntnt:
6.Total Project Cost: $ �v1 .13 Paid in Full p Outstanding Balance Due:
ZZ
i
1
5'ECT iO1N 5: CONSTRUMOPI SER�'ICRS
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder �- . '
List CSL Type(see below)
No.and Street13eaeriptmoa
U I Unrestricted to 35 000 Ca.R
R I Restricted l&2 FamilyDwelling
City/rown,State,ZIP M I Masonry
RC Roofing Covering
WS Window and Skiing
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date .,
HIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /Town State ZIP Tel hone
SEcrwN VYU KERw l omml 1wIY3id mURANCE AFmAvrr(M.G.L c.152.3 25Q6))
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...........O
7a OW9VER AUTAbRIZATION TO 919 CO LETEA WHEN
WXE,R'S AGM 4R 9 FO_ HNG PRit11 IT
1,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 711b:OWNEW OR AUTH ?TUM AGENT IECLARATI(W
By entering my name elow,I hereby attest under the pains and penalties of perjury that all of the information
conta din this a p cation is true and accurate to the best of my knowledge and understanding.
i
prm is Name(Electronic Signature) Date
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 can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dns
2. When substantial 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 substituted for"rota]Project Cost"
(f� QTY OF SALEM) MASSACHUSETTS
BUILDING DEPARTMENT`
;y 120 WASHINGTONSTMET,3"OFLOOR
TEL.(978)745-9595
KIMBERLEYDRMCC)LL FAX(978)740-9846
MAYOR THOMAS ST.RERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING OOAWSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT. /
Date b / �g / 26��
Job Location_ 3 I 'DOW Sdi m MO j)I q`]o
Home Owner Address SUING
Present Mailing Address SU V11�
The current exemption of"Homeowners"was extended to Include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that does not possess a
license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or
is intended to be, a one=or two-family dwelling,.attached or detached structures accessory to such use
and/or farm structures. A person who construcs more than one home in a two year period shall not be
considered a homeowner. Such "homeowner"shall submit to the Building Official,on a form acceptable
to the Building Official,that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner"assumes responsibility for compliance with the State Building Code and
other applicable by-laws and regulations.
The undersigned"homeowner"certifies that he/she understand the Cit of Salem
Y Building ldmg Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNAT 7
APPROVAL OF BUILDING INSPECTOR
i
i
CITY OF SALEK MASSAaASE TP,
BUMUMDarAXnWn'
120 WARDUM vS77t8 OrR OOR
DL(M745-9599.
FAIL MD-9W
B�RIBYDRbS00d1,
MAYOR MMUSMEM
Dnt cmacrrLmuCAMopBR7Y/BumnmamenocNm
Construction Debris Disposa/Af rdavit
(required for all. demolition and,.renovation work]
in accordance with the sbM edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40,S 54; BWldirgi Permit R is Issued with the
condition that the debris resulting from this work shag be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111,S 151.
The debris will be transported by.
I� S
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
z02LO .
Date