0019 KOSCIUSZKO STREET - BPA-16-1035 I Z �°�
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code,780 CMR Revised Mm 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
n One-or Two-Family Dwelling
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Bttilding Per�lt Number - Date Applied:
-- lleilding Ol&cial.(Prmt e) ' -� 4
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1Z Assessors Ma &Parcel Numbers y ;
� 1.1 Property Address: P N
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1 umber
Parce N
W K o S 1 S 7 �� 1
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Map Number
et? es n
1.18 Is this an accepted stye y
13 Zoning Information: 1.4 Property Dimensions: fif
Zoning District Proposed Use Lot Area(sq 11) Frontage(11) �, r
1.5 Building Setbacks(B)
Front Yard Side Yards Rear Yard
Requirod Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage g Disposal Po SYstem:
Zone: _ Outside Flood Zone? Municipal❑.On site disposal system ❑
Public❑ Private❑ Check if yes13
9EtTLON2: PROPRTYOWNERS7IIYt
2.1 Owners of Record: SlKM O I d
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Name(Print) City,State,ZIP
Dal KS.--t
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No �d Stret Telephone Email Address
SECTION Bt DESCRIPTION OF PROPOSED WORK'(eheck all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work"
SECTION 4:ESTBkiATED CONSTRUCTION COSTS
Estimated Costs: Official Use.Only
Item (Labor and Materials
1.Building $ 4 0-r 1. Bttlltiing in
Permit Fee:$ Indicate how fee is determed:
❑Standard City/fovm Application Fee
2.Electrical $ o c7 p Tow project Cose(Item 6)x multiplier x
3.Plumbing $ r 2. Other Fees: $
4.Mechanical (HVAC) $ Lisa:
5.Mechanical (Fire $ ToYdi All Fees:$
Suppression)
Check No. Cheek Amount: Cash Amount:....
6,Total Project Cost: $ 1 tTIIa ❑paid in Full ❑Outstazt Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor license(CSL)
G7a7�eG $hI l
ChGLrIL�SnI N� License Number Expiration Date
Name of CSL Holder
list•� ��Sir C C'� CSL Type(see below)
No.and Street T"C Ilmserrption
S�1 l U Unrestricted(Buildings u to 35,000 cu.R
K R Restricted M2 Family Dwelling
"
City/Town,State,ZIP M
RC RoofingCov '
Ws Window and Sidioe
SF Solid Fuel Bummg Appliances
Ssa3 ceJ ) 3 I Insulation
Telephone Email address D Demolition
5.2,Registered Home Improvement Contractor(HIC) , a 7 ILI
kA L.S wt\r LI— HIC Ria--g! Expiration Date
HIC Co any N e or HIC t Name
N-Cv s e'A Q l n L'G TI ESl B S p3 Email address
Ci /town State ZIP Tel hone
SECTION tb WORKER34 COMPENSATION INSURANCE AFFHIAVIT 0.LG.L.c.152.3 2SQ45))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuan f the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
keffbN 79r AUMAMMATION_ TO BE COPOLETEID WHEN
t)WNE •s AUNT CO CTOR. 1FI1 IIVG
I,as Owner of the subject property,hereby authorize 2 S r
to act on my behalf,in all matters relative to work authorized by this building permit aication.
Print Owner's Name(Electronic 'goature) Date
SECTION 7b: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
contained in this application is true and accurate to the best of my knowledge and understanding.
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Print Owner's or Authorized Agent's N (Electronic Signature) Date
NUTS
1. An Owner who obtains a building permit to do his/her own work,or an owner who hives 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 can be found at
w�vw.mass. oy v/oca Information on the Construction Supervisor License can be found at Mn .mass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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"