9 FAIRVIEW RD - BUILDING PERMIT APP 1
/ The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
e Massachusetts State Building Code,780 CMR,7m motion OF SALEM
RevisedJwnwy
Building Permit Application To Construct,Repair,Renovate Or Demolish a 1,2008
One-or Two-F "y Dwelling
This Seqi66 For Official Use Only
Building Permit Num Date Applied:
Signature: St, ('l P L- D
Buil ' 'o of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: V / 1.2 Assessors Map&Pared Numbers
9 FCtirr ) s r"J 1�.c9cxcl
Lla Is this as accepted stred7 yes—Z no MV motor Parcel Number
1.3 Zoning Information: 1A Property Dlmeealom:
Zoning District Proposed Use Lot Area(sq/1) Frontage(8)
1.5 Building Setbacks(it)
From Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Waster Supply:(M.G.L c.40,§54) 1.7 Flood Zone Iaformadon: 1.8 Sewage Disposal System:
Public H Private❑ Zone: _ Outside Flood Zone? Munic�al a'Oo site disposal system O
Check ifyesO
SECTION2: PROPERTYOWNERSHIPr
2.1 aero of Reer:
Name Address for Service:
t� Si Telephone l
SECTION 3:DESCRIPTION OF PROPOSED WORle(check all that apply)
New Construction 13 Existing Building d I Owner-0ocupied D 1 Repairs(s) 13 1 Altorafioo(s) Addition ❑
Deriwlition 13 1 Accessory Bldg.O Number of Units_(_ Other ❑ Specify:
Brief Description of Proposed Work 2 _ C r 2 ,1 A v
C fr v0 /cvn
a e ( oe,Q c o eTs
q -1710NI-EST11164TEDCONSTRUCTIONCOSTS
Item Estimated
os Official Use Only
1.Building $ S� S I. BuildingPermit Fee:S Indicate how fee is determined:
2.Electrical g _O / O Standard CrtylTown Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing S o0,/ 2. OthcrFoes: $
4.Medtanical (HVAC) S List
5.Mechanical (Fire $
S 'on) Total All Fees:S
(perk No. Chock Amount Cash Amount
6.Total Project cost TO 7 13 Paid in Full o Outstanding Balance Due:
��� 7 ��
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
cs 9 y/Y-ao1"Z
Rn v\ O SGc ^C� License Number Expiration Date
Name of CS1,Holder List CSL Type(see below)f7 L
72
Address P Type Descrildim
INv� fM U UmestrrUed to 35,000 Ca Ft
R Restricted lA2 Family
M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Wmdowand Siding
<7 '�/� "ris-9/q SF ResideMiaISolid Fuel Bunang Appliance histallatum
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) ///,577
19CC�y Name or
Ka �n St�t�.7�/3 ReB�mation Number
1 b�
Address �/O "/1
IC S2hr11— S � � �L�2�.-taa,V.L 1 - ExPbatien Date
Si Tel �=o�j
SECTION 6:WO RS'COMPENSATION INSURANCE AFFIDAVIT(NLG..e-15L§2SQ6))
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........ _
SECTION 7n.OWNER AUTHORIZATION TO BE COMPLETED WHEN
O 'S AGENT OR CONTRAqWR APPLIES FOR BUILDING PERMIT
)I, I `-'P� I ' as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authori by this building application. p 7
St o r Date
f SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
e— � ` �2 %�Gas 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
u
Signature
�of Owner or Autho " gem — /u
(Signed' under the pains and penalties of
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 fiord 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 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished bascrnent/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"maybe substituted for"Total Project Cost"