23 HANCOCK ST - BPA (002) QQQ The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
OF SALEM
Massachusetts State Building Code, 780 CMR, 7"edition
r✓ Reeised Jwwury
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Familyelli
This Section For,Offtcial U e Only
Building Permit Number: rDate At d:
Signature:
Building Commissioner/Inspect"o ildings ate -
SECTION 1:S E INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
S'r[.to 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 It) Frontage(0)
1.5 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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system 13Public❑ Private❑ Check if es❑ P y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record,,,,,.,,," 1
TA H a� a..i r r_
Name(Print) Address for Service:
9 -1 ?Z-14 l 7 S 1 'J
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Buildi Owner-Occupied Repairs(s Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other ❑ Specify:
BriefDescrip[ionofProposed Work': MY -:i 1. Rc,v IF ¢ (=LAT RODS S-r-a.t•J2
��Psn R, 9-- F
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building S I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S C3 Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4.Mechanical (HVAC) S List:
5. Mechanical (Fire S
Su ression) Total All Fees: S
e Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S 5(��� 0 Paid in Full 0 Outstanding Balance Due:
1
1 . SECTION 5: CONSTRUCTION SERVICES
5.11 Licensed Construction Supervisor(CSL) 9 �-(1 1y,3 ` ( 4
1 �C>\n V oyc License Number Expiration Date
Name of CSL-I lulder t�
14�iMAta ST— t"P4tin,nY List CSL Type(we below)
ndd s5. r Description
U I tlnrestricteJ(up to 15,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Si nature M Mason Only
�4i s---2.k �7 RC Residential Rooting Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burnina Appliance Installation
D Residential Demolition
5.2 Regbtered Home Improvement Contractor(HIC)
L9. , !mac Y C, r
f IIC Company Name ur f11C Re tstran a Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 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 of the building permit.
Signed Affidavit Attached? Yes..........❑ No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 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
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I, L e;o� G4 b. ALV Co-,-', ,as Owner o Authorize ARentt ereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner o Auth 'ze A ent Date
(Signed under the pains and penalties of 'u
NOTES:
I. 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 nom,(have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.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
1. "Total Project Square Footage"may be substituted for"Total Project Cost"