18-20 ORD ST - BUILDING INSPECTION Vqc c.K zrig
The Commonwealth of Massachusetts
i'. A ' OF
Board of Building Regulations and Standazds SALEM
Massachusetts State Building Code,780 CMR ,i`�'�'�t�� n R�visg�LMar 2011
Building Permit Application To Construct,Repair,Renovate2&DQ&l1Q a J9
One-or Two-Family Dwelling
(� This S.edaon Fur Of&cial Usa Ont '
Building permit Number Date APpHed:
1luilding Official(Kiat Nerve) Signature - Date
SECTION 1:SITE 1NPORMATION
1.1 Property Ad ass' X1.2 Assessors Map&Parcel Numbers
1.1 a 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 ft) Frontage(ft)
1.5 Building Setbacks(tt)
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? Municipalq.On site disposal system 13Publi 'qAQ Private 13Check if e6X
SECTION a: PROPERTY OWNERSKIPt
1 rQ1w'►�� cZd:
NarnRe(Print) 1 �1 T— Ci ,State,ZIP
�- 1!?•
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK;(eheck all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 19f Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work": k l Q a I n 110� 1AA2 11 Q2
5 I Je 1-C
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OfScial Use.Only
Item Labor and Materials
I.Building $ �S 1. Building Pemrit Fee:$ Indicate how fee is detgrminedi
13 Standard Cityfrown Application Fee
2.Electrical $ — p Total project Cost"(Item 6)x multiplier x
3.Plumbing $ — 2: Other Fees: $
4.Mechanical (HVAC) $ — List:
5.Mechanical (Fire $ Total Ail Fees:$
Sssion
Check No. Greek Amount Cask Amount:
6.Total Project Cost: $J3 OLS 00 ❑pall in Fall ❑Outstanding Balance Dae:
61fig" 2-1 C' - -1 4 _10 PAL.,
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisoi License(CSL) OS�189 S OS�3 /
License Number Expiration Date ,
Name of CSL,Holder '-"• 01
t R
pO✓ / � ^ f�Q� Q 1 List CSL Type(see below) iC
No.and Street (� Type Description -
kr A� 35,000 w.ft.
R I Restricted l&2 Family Dwelling
..
City/Ibwn,State,ZIP M I Masomy
zqe J , n���C RC WmdoRoofiDCnd Sin
C.' th0✓ ✓'�(TI 7 WS Window�dSi '
SF Solid Fuel Burning Appliances
9 48• 936.32 1 1 Insulation
Telephone dress D Demolition
5.2 Registered Home mp/r�ovem // ontrJactor(HIC) J g WSJ�' o)/j A he-
C-y t.vf1 cerci C.*S GO S7' t"VG Il o. HIC Registration Number Expiration Date
11 1'ompg rN+a-7-t C!HIb . e
No.Sotr ?
_q1
Email addresse , AAq 1,3-}O 6. 707
Ci /Town State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(ALG.L:c.152.§ 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 ..........O No...........❑
SECTMN 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
QWNER'S AGENT OR CONTRACTOR AMaS FOR 13IMG
w. 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 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
conta' d in this a plication is tru"d accurate to the best of my knowledge and understanding.
P wt Owner's or Authorized Agent's Name(Electronic Signature) Date
NgTES= '
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.c. 142A.Other important information on the HIC Program can be found at
jmymn ass.gowoca Information on the Construction Supervisor License can be found at www.mass.eov/dns
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 halFbaths
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"