7 ELM AVE - BUILDING JACKET The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Ulf
Massachusetts State Building Code,780 CMR, 7 h edition. OF SALEM ---
l Revised January
Building Permit Application To Construct,Repa Renovate Or Demolish a 1,2008
One-or Two-Family elli g
This Section Fo Offrcial tse Only
Building Permit Number: Date 1' y
Signature: ) ���✓/��
Building Commissioner/Inspector of B m D gs ate
SECTION 1: SIT INFORMATION
1.1 Property�/1zlr Add s: 1.2 Assessors Map&Parcel Numbers
l'7 ��"��
1.Ia 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 tt) 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes[]
SECTION 2: PROPERTY OWNERSHIP'
Owner'of Re rd:
2fr1,r2x E I P7 &Zin S& A
Name(Print) - Address for Service:
4, 9 'W--7ya - 5903
Signature - Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK''(check all that apply)
New Construction❑ n Exist g Bu ilding❑ Owner-Occupied ❑ R epairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Des ription of P oposed Work2:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ zry 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2.Electrical $
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees: $
Suppression)
aJ Check No. Check Amount: Cash Amount: i
6.Total Project Cost: $ `7 Ll 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) )57� 7�3.
ZLicense Number Ex iration ate
Name f SL-dold
' List CSL Type(see below)
Add re f Tye Description
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
M Masonry Only
L� RC Residential Roofing Covering
Telephone ' WS Residential Window and Siding
SF Residential Solid Fuel BurningAppliance Installation
D Residential Demolition
5 Registered Home Improvement Contractor(HIC)
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HIC CompanyName or C Re strant Na e _(' Registration Number
A Al lay
Ad
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(J f/
eSignature elephone Exration to
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.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 Issuan of the building permit.
Signed Affidavit Attached? Yes .......... V No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR B�UILDING PERMIT
I, /�m daAe_ to S7t& /0 as Owner of the subject property hereby
authorize / to act on my behalf, in all matters
relative.to work authorized by this building'permit app ' ation.
A &
Signatureat 0 Owner Date
y SE..C,,TI/�ON_� 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
Mas Owner or Authorized Agent hereby declare
that the statements andlinfonnation on the foregoin plication are true and accurate,to the best of my knowledge and
behal
Print Nam
Signature of Owner or 21ho-iNped Agent ate
Si ned under the pai: d pbnalties of er'u
NOTES:
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O R6 and 1 I O.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"may be substituted for"Total Project Cost"