29 HANSON ST - BPA 25 C*-- It f7
t The Commonwealth of Massachusetts r , VIC-2-CITY OF
9 =cr
Board of Building Regulations and Stand SALEM
Q Massachusetts State Building Code,780 CMR Cep q p ;lsed Mar 201]
Building Permit Application To Construct,Repair,RenOAP) e�olis9 a
1p One-or Two-Family Dwelling
�j Building Permit.i3tanber: Dtde - p>ieti:
e
SECTION I.BITS#NPOBMATT fI!1
1.1 Prope Address: 11.4
.2 Assessors Map&Parcel Numbers
1.1 Isthis an accepted streeyes� 0
ap Number Parcel Number
1.3 Zoning Information: Property Dimensions:Zomig Districtpied Use ot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
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 13 on site disposal system 12Public 13 Private❑ Check if yes❑
SECTION 2: PItOPERTY'OR 1YERSHIP2
2.1 OwneI of Record: /1
Vit oS (o Yr
Name t Ctty' tate'ZIP
29 �
No.and Street Telephone Em Ad
SECTION 3:DESCRIPTION OF PROPOSED WORK'(ohe&aftthat apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ SpedfY:
Br efDeselptio o Proposed World:
',.,
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials
1.Building $ ' g0 l7 1. Bui&Ilog Pen°]t Rea:$ — Indkate now fee is determined`;
❑Standard City/Town Application.Fee
2.Electrical $ p Total Project Cost'(Item 6)x multiplier —x-
3.Plumbing $ 2. Other Fear: $
4.Mechanical (HVAC) $ :
5.Mechanical (Fire $ Total All Fees:$
STession Amount Cash Amount:
6.Total Project Cost: $ / .S D C) ❑Paid in Full ❑Outstanding Balance Due:
I� 1pho� 'kA P ')
SEMON s: CONST UMON SI6RVRIES
5.1 Construction Supervisor License(CSL)
License NumberExpiration Date
Name of CSL Holder '* "
Lis[CSL Type(see below)
No.and Street
Tjrpc Description .
U I Unrestricted(Building to 35,000 cu.fL -
R Restricted l&2Family Dwellin
City/Ibwn,State,ZIP M Masonry
RC Raiding Coverm
WS Window and Siding
SF Solid I=]Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name -
No.and Street Email address
Ci /I•own State ZIP Tel hone
SBCTLON&WDRIGM'COMPENSAnON ROURANCE AWMAVIT(MC�L.c 152.§25G(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...........❑
SECTION 7a OWNER AUTH RIZA TO Biu COA4ELETEA N
OWNER'S QR CTOR INCz P$R111<11
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.
Print Owner's Name(Electronic Signature) Date
SECTION 711:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
con . ed in this application is true and accurate,to the best of my knowledge and understanding.
Print Own 's or Au o ' d Agent's Name(EI me Signa ) Date
M.
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 fund under M.G.L.a 142A.Other important information on the HIC Program can be found at
wnvw.mass. oy v/oca Information on the Construction Supervisor License can be found at mnD .mass.gov/dos
2. When substantial work is planned,provide the information below:
Total floor 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"
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