11 BURNSIDE ST - BPA-2009-788 � The Commonwealth of Massachusetts Townof
Board of Building Regulations and Standards
e?� Massachusetts State Building Code, 780 CMR, 7"edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Tivo-Fornily Dwelling
This Secti or O t ial Use Onl
Building Permit Numb :/f ate pplied: `
Signature:
Building Commissioner/Inspect r of Buildi Date
SECTION 1: FORMATION
1.1 Property Address: �- 1.2 Assessors Map At Parcel Numbers
/�
1.1 a Is this an accepted street?yes Z no Map Number Parcel
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(R)
1.5 Building Setbacks(D)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(MAUL C.40,954) 1.7 Flood Zone Information: 1.8 Se ge Disposal System:
\ Zone: Outside Fitone? Muniapal On site disposal system ❑
Public L¢ . Private❑ Check if
SECTION 2: PROPERTY OWNERSHIP'
2.1�,YYneo(�d Pitt��t—Rec rd: rI-l`t_91 D�—,
Name(Print) Address for Service:
Fier 1L Com. OQ20 �(C q'7Ss! 7"1 l
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ Alteration(s) Addition ❑
Demolition O 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Official Use Only
Item Labor and Materials
I. Building I. Building Permit Fee: E Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing E 2. Other Fees: E
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S - Total All Fees: 5
Suppression)
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S fSzw / ❑ Paid in Full ❑Outstanding Balance Due:
15-
-7
s7
� 5
r /
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) <,c
�27���yi,/T��' �O�t�� Lirensc Numbr7r Ea irauon Date
Ngme ul CSL- HprladeF- p Liu CSL Type Isec below)
�t
Add=s. Type Description
I U f
Restricted
l u to Family
Dwelling Cu. Ft.)
Signature �`-�-�— R Restn ry I&2 Famd
M Mason Only
RC Residential Roofing Covering
Telephone WS Rrsidential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Regnistered H/pme Improvement C rector(HIC
it/0-/eWA- /� !/H!`'-&O. 1 /J , -f4
HIC Company Name or HIC Re Istran�t Naamp, Registration Number
10
piration Date
Signature Ty`Y"� Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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 4suance of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a:,OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWN 'S 4eidENT OR CONT COR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize P to act on my behalf,in all matters
relati tow rk authorized by thij Iding permit application.
Si nature of Owner Date
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.
Pnnt Name (yIAZV xJJ��)**99
Signature of Owner or Authorized Agent .9 .rl Date ` '"""��
(Signed under the pains and penalties of
r'u
NOTE
I. An Owner who obtains a building permit to do his/her own work, r 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.) 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"Total Project Cost"
o,
15 -Old Style 1 Fair LOC=SCHOOL. 13
- 3 -Brick/Stone
1 -Wood 6
11 -Asphalt ---
6i 8 EFPS
".+ 04 -Flat ►, Prima 1 (48)
01 -AsphaltSh I ,, 1 `,`,. Fair ' J. ..1, k
BLUE ..,
# 1 MoFair 4
4 SFL 41
C- ENW FFL
1870 .6 3 i BMT
(683)
. sa,
s .
• s i• 6 3. M 17
i+
a STD * , FR -Fair 38.
02 -Plaster
- • L -Location 5 � ' _ .. ...
s T -T al + °• 19 6
+ 03 -Hardwood 1 11 61 3
12 -Concrete
107.00 BMT Basement 683 28.460 19,440 1
--�
__. 6.
FFL First77,759 .
3 -T pial Is o 683 113.850
Second
, ..i
SFL Sentl Fl floor 683 113850,. 77,759
2 -Typical + 0.893659
1.19063 EFP Enclos Porch -48 31.200: 1,498
8 113.850 - ENT ENTRY16 11.5501 185
- - 2 -Gas ..- 0.90 _ _ __.
__ . 11
-. 06 -Elec Base/B - 17425 -- -
1.00 , ' =. 2,113 -
NO NO �, + . 174659 75.18 s 1366 • •, 2113 0 1366 -_
s . #•: • e 71942 0 48.00 -- ..
102717 ITUT2700 -75.18
PARCEL ID 36-0159-0
_ a
07 Pool A-C D Y 1 16 AV AV 1870 i 85.55 T 40.8 101 800 - 800
02 Frame Shed I D Y 1 70 - AV AV 1870 7.75 T - 40 101 300 300
1,100'..
=y' `` 6 0159 0 1 of 1 Residential TOTAL ASSESSED: 197,900
Map Lot Suffix CARD Salem 14355!
PROPERTY LOCATION IN PROCESS APPRAISAL SUMMARY
11 BURNSIDE STREET,SALEM 101 102,700 1,100: 010494,100' 197,900 p
OWNERSHIP
CLOCHER FRANK B --.. ........ __ _. -_...
PAULINE R
102700! 1,100 0.10494,100 197,900 ::- Patriot 11 BURNSIDE STREET 102,700i Moo 0104: 94,100 197,900 , , Pa r io
. Markel Cost + •• • . 144.88 - -- - 144.88 ,, ��A Properties bw.
— 08/06/96
SALEM PREVIOUS ASSESSMENTr 1: Adis
ParcellD X36-0159-0 USER DEFINED
I'llMA 51111111w'plj� .. - '21
LN rikii : chlig 11
01970 2004 101 FV 91,600 1100- .104 91,400, 184,100:. 184,1Wroll 1/20104 PRINT
PREVIOUS OWNER 2003 101 CV '.. 91,600 1100. .104 91,400,, 164,100'.. 184,100',conversion 117104
2003 101 FV 52,200 1100. .104 101,800.. 155,100,, 155,10OYear End 117/03 07/11!05 2:22:15
U;=E:--:::]
2002 101 FV 48,900 1100 .104 78,300, '114/02
2002 101 . TS 1 48,900 1100. .104 78,300: 128_,3.00_ 1214101 LAST REV
2001 101 10 - - 0 -- 104 - 121200 LA10 11120/00 071
2001 101 IV 48,900 1100 .104 _71,200, _ 6/6101 04 08:44:13
2000 101 FV 52,100 0 .104 61,300; 113,4001 ICONV 2117/00 apro f
NARRATIVE DES RIPTION SALES INFORMATION PAT ACCT. 1 4355
This Parcel contains.104 Acres of land mainly classified as IMNIME
One Family with a(n)Old Style Building Builtabout 1870, ---- ---- �3986-308 111100 No No--- ---- ---- --- --- --- -- - -- --
Having Primarily Asphalt Exterior and Asphalt Shgl Roof Cover,
'th 1 Units,1 Baths,0 HalfBaths,0 314 Baths,6 Rooms,and 3
FQEJ ASSE 1MENTS
'; ill
- BUILDING PERMITS ACTIVITY INFORMATION
— --- ----------. — -__-.-
4122104 876-2004 Redo Kit 65 C KITCHEN REMODEL 6/25104 Permit Visit 379 CW
12/22799 Measured 272 :PATRIOT
F7FeV0
: 8/6196 Inspected .RA ';RA
PROPE
------ --- YEftIFIGATION OF t�S1T NOT DATA
1010ce Family, 4551_,- Sq,.FL Site 0 793: 2.607 EP 1,00 003194,092- _,. ,,- 94,100
101 One Fam9y -,- 41 Front Ft Site 0I EP 100 003
..-.. .......
i
0.104477 4551.00 flIM101 jOneFami EP 94,092 94,100