17 GABLES CIR - BUILDING PERMIT APP The Commonwealth of Massachusetts
Board of Building Regulations and Standards SALEM
W
Massachusetts State Building Code, 780 CMR Revised Slur 1011
To Construct Repair,
Renovate Or Demolish a
' in Permit Application P
ButIJ g
One-or Two-Family Dwelling
T This Section For Official Use Onl
N Building Permit Number. Date A lied:
A*
Building Otticial(Print Name) Signature : m
SECTION l:SITE INFORMATION r rn
_ _m
( I.I Property Address: 1.1 Assessors Alap&Parcel Numbers <
n F_ CD
L la Is this an acce ted street?yes no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions: r'
—i M
"Luning District Proposed Use _Lot Arca(sq 11) Frontage(R)
L5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided. Required " Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ - Zune: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es❑. .
SECTION I: PROPERTYOWNERSFI10'
2. Owner of Record• S�/C m � 19
F9(/h �=SB iNw� t
17 a(Print) - City,State,ZIP
cr c 00
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(cheek all that apply)
New Construction❑ 1 Existing Buildin Owner-OccupiedK1 Repairs(s) Alteration(s) O Addition O
Demolition ❑ 1 Accessory Bldg.O 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work-:
Grr Nr'rc.l N0"1 r`l e N cxN e e
SECTION a:ESTIMATED CONSTRUCTION COSTS
Itcm Estimated Costs: Official Use Only
Labor and Materials)- - -
I. Building S aiI—/pp p I• Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical S ,S O ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S spa 2ptherFees: s
4.blechanical (FIVAC) $ List:
5.Mechanical (Fire S 'Total All Fees:S
Suppression)
po Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 3J J UDO ❑Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSI[RUCrION SERVICES
5.1 Conns_tr_uctionnSnse(CSL) CS 08"200-3
License Number Espi alion Uate
Name of CSL Flolda List CSL Type(see below)
07 'rDescription
No.mrd Street
g� nn
p�Uo_'/ �11 � C bac R Restricted 1&2 uFamily
Dwelling
lt.
Cilyfrown,State,ZIP M Masonry
RC Roofinx Covering:
WS Window and Sidinst
SF Solid Fuel Burning Appliances
Insulation
Telephone Email address D Demolition
S.2R �SWisteVredoelmprtiolventContractor(HIC)
� N/ 2�111 y �6
S - HIC Registration Number Erpirution Date
1IIC Cunt an Name PPr HIC Re strant Name TT JJ ��tt nn ��JJ��
�(c7 p�ow21< <1- JUhNaoyyl404,1 (9r/rti' r, ,Cc
Nuh _ �`I ( �� O1rgnG g�p /l/���OY Emuiluddress
CiV/fown`SState ZIP 1Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFF[DAVIT(M.G.L F.ISi.§2SC(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 Ishuance of the building permit.
Signed Affidavit Attached? Yes.......... No...........O
SECTION 7a;OWNER AUTHORIZATION TO BE COMPLETED.W HEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING.PERMIT'
1,as Owner of the subject property hereby authorize U0� V0��t a A f
t9 act on my behalf,in all matters ative t V
uthorized b 's building permi application.
C, _ZZ 7/
Print Owner's Name( lectronic ygrautirel Dam
SECTI N 7b:OWNEW ORAUTHORIZED AGENT DECLARATION
By entering myarae below, ereby attest under the pains and penalties of perjury that all of the information
contai int s applicati i true nd accurate to the best of my knowledge and understanding.
ZI
Pr wn is or Authorhidd Agent's Vine(Electronic Signature) D
NOTES:
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 no have access to the arbitration
program or guaranty fund under hLG.L.c. 142A.Other important information on the HIC-Program can beeotmda
www.mass.eov:'oca Information on the Construction Supervisor License can be round at AAA&tass.�
2. When substantial work is planned,provide the information below:
Total fluor area(sq. R.) (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 ofcooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"