152-154 BRIDGE ST - BUILDING INSPECTION ' C-4< 1013
The Commonwealth of Massachusetts CITY OF
i� Board of Building Regulations and Standards SALEM
4)t Massachusetts State Building Code, 780 CMR Revised blur 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fmnily Dwelling
This Section For Official Use Only ?
Building Permit Number: ate Appliedt �^ m
( z
'� DuilJing OlTciol(Print Name) : Signature ®ate J—
SECTION 1:SITE INFORMATION" r
1.1 Property Address: 1.2 Assessors rAlop& Parcel Numbers �
iso-iry f3�LTpC sY <
L I a Is this an accepted street?yes no Map Number Parcel Number Ln
1.3 Zoning Information: LJ Property Dimensions:
Zoning District c Proposed Use Lot Area(sy(1) Frontage(11)
LS Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided. Required Provitled
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❑ On site disposal system ❑ -
Public❑ Private❑ �.- . Clucklf as❑. -
SECTION 2. PROPERTYOWNERSHIP!'
2.1 Oof Record:
/�h
City,State,ZIP
�nC/5P s7' 9)9-yM3-08- 3
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Buildin Owner-Occupied Repairs(s) Alteration(s) E3 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other O Specify:
Brief Description of Proposed Work'
T V r - ce cr, c wS
ICA
SECTION 4: ESTIMATED CONSTRUCTIO, COST
Item Estimated CoJE3
Of1(cial Use Only
Labor and Mat
I. Building S UGI. Building Permit Fee:S Indicate how fee is determined:
Standard Cityaown Application Fee
2.Electrical S ❑Total Project Cost'(Item 6)s multiplier s
3. Plumbing $ Qther Fee
2 s: S
4.,Mcchanical (FIVAC) S List:
5.iMechmtical (Fire i "total All Fees:S
Su ressiun)
�I Check No._Check Amount: Cash Amount:
G. Total Project Cust: 3 �� �GV 0 Paid in Full 13 Outstanding Balance Due:
1
SECTION 5: CONSTRUCTION SERVICES /� 7
5.1 Construction Supervisor License(CSL) 5 7�3 67
d\" Q�, "r�� f License Number Expiration Date
Namc of CSL[foldery
11 �n list CSL'rype(see below)
p� Description
No.and Street U Unrestricted Buildin a to 35.000 cu. It.
SISaCD` W A 01 l be, Restricted l&2 Family Dwelling
Oty/Ibwn,Slate,ZIP N Masonry
RC RoolingCoverinat
WS Window and Siding
n n ^y SF Solid Fuel Burning Appliances
Iaaulalion
GNN C+�� bbb
ele hone Email ad� .60w D Demolition
5.2 Registered Home Improvement Contractor(H IC) �WVel2
HIC Registration Number xpirution Dnte
111Cuntan nor IIC Re istrant r�
p Y nine Name
4-P �.�. t d �A^[1 G///(•/� ////Y/0.:/' C¢✓'-r
No..lyd Street Em it ad
&/P GG
ro t i vvl � G`l9
Cit /Town State IP Tele hone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G,L:c.152.¢ 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 Is§uance of the building permit.
Signed Affidavit Attached? Yes.......... No...........O
SECTION 7a:OWIVER AUTHORIZATION:TO BE.COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLI(E9 FOR BUILDING PERMIT`
1,as Owner of the subject property, reby authorize 6V�t A QC�� IV
t9 act on my behalf,in all mattersr ative o wor uthorized by this building ped it application.
61 Av mv19k
Print Owner's Name(Electronic Si pure) Date
SECTION 7b:OWNER!OR' UTHORIZED AGENT DECLARATION
By entering my name below,)hereby attest under the pains and penalties of perjury that all of the information
;ontai in thi pplicatio ' t e a accurate to the best of my knowledge and understanding.t wne sur Atnhoriz Agent's Nm (Elecuontc Sigtmture) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or art owner who hires an unregistered contractor
not registered in.the Home,improvement Contractor(HIC)Program) will no have access to the arbitration
-- --
progi•am or guaranty fund under NLG.L.c. Ia2A.Ofher important tmf6ima ien on tbeHICPedgmm can be oun d at--- ___---_------
www.m:tss.uov'oea Information on the Construction Supervisor License can be found at AwA.nlail eov%'Jits .
2. When substantial work is planned,provide the information below:
'rotai floor area(sq. ft.) "A (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 healing system Number of decks/porches
'rypeofcoolingsystem Enclosed Open
3. "Total Project Square Footage'may be substihncd fur"'rota) Project Cost"