8 CHARLOTTE - BUILDING JACKET / The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
y r Code, 7'80 CMR, 7ib edition OF SALEM
Massachusetts State Building RevisedJonuart•
Building Permit Application To Construct,Repair, Renovate Or Demolish a (• =///LY
One-or Two-Family Duelling
This Se• 'on For Official Use Only
Building Permit N ber. Date Appli d:
Signature: (J/&7. • X— /cZ 12
Building Commissioner/Inspector f B ' i gs Date
SECT I:SITE INFORMATION
Lgroperty Address• / ' 1.2 Assessors Map& Parcel Numbers
—1.I a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq Il) Frontage(Il)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provide)
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?Check 13 Private❑ Check if yesO Municipal[3On site disposal system ❑
o vin SECTION 2: PROPERTY OWNERSHIP'2. �/
Na (Pn�✓t7 � ¢ t ry L�✓�G 04W T/Gi
Nome(Print) '�� Address 1'or Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Afteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Desc iption of Proposed Work'-• .o
W,Adold 5 repil'4
q [�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I. Building S S l00 0 1. Building Permit Fee:S Indicate how fee is determined:
�. Electrical S
13 Standard Cityrrown Application Fee
❑Total Project Cost' (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Su ression) Total All Fees:S
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S ��� ❑Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
Il 1cense Nu other ppirutiu Date
Nunn ul'C'SL-1lo1 / �r / List CSL Type Isee below)
y
o G �/2�
Address qq �J f' Uesc
00 tion
P (/L R Restricted I&?Family Dwelling
Signmur�/e G� /, M Sluson Only
Residential Rooting Covering
I elephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
��5.2 H iste ed Home rovementCo tractor HIC)
,- �''
1IIC' piny N', a or HIC Registrant �gistratiun Number
fC_
Address-1 /
9 �J/7�� f ripimtio Dam
Signature .releph e
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 Issuance f the building permit.
Signed Affidavit Attached? Yes .......... Nu...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, i)I __, 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.
Signature of Owner Date
n SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
10
I, �J 4-U( ld&LC/— ,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 /NameT� /f 1 �7(�/�.v' /rs
Signature oft i ner or Au horize Agent Date / a(
(Signed under the pains and penalties ofperjury)
NOTES:
L 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.) Ilabitable 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 fix"Total Project Cost'