B-19-321 - 0033 1ST STREET - Building Permit c� s 3 3g
rz. The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY Massachusetts State Building Code;780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
�N Building Permit Number: Date Applied:
�- Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION'
1.1 Pro erty A dre 1.2 Assessors Map&Parcel Numbers
I3 . S j `:7
L l 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(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'
2.1 �O er'of ord:
`.J h n ile r— /PYrrl r.n es
Name(Print) s t City,State,ZIP
3� l Sf-. 339-a53 - �5�)
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ I Repairs(s) ❑ JAlteration(s) ❑ Additiqu,,❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other Specify: ' ice,
Brief Descriptio of Proposed Work2- - s
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only F
Labor and Materials rtt
1.Building $ 301V, 1. Building Permit Fee:$ Indicate how fee is det;rnn ley
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (I VAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No.LE Check Amount: Cash Amount:
6.Total Project Cost: $ �� , ❑Paid in Full ❑Outstanding Balance Due:
I
N SASE
t -
'T SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) '9 7 97 7
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
Flick W D.�1�..,
No.and Street Type Description
3 kiltdn St. U Unrestricted(Buildings up to 35,000 cu.ft.)
Salem_ MA 0-1970 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) /112—0,9 G 1.2—k ,
HIC Registration Number Expiration Date
HIC Company a r Re is nt Name
ers a venue
No.and Street SalewMA 01970 Email address
City/Town,State,ZIP Telephone
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 Issuance o building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUIILDING.PERMIT
I,as Owner of the subject property,hereby authorize F_f G A`
to act on my behalf,in all matters relative to work authorized by this building permit application.
Z-7
Print O er's Nam (ElectronicSignature) Date
SECTION 7b:OWNER'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 annfica*on is true and accurate to the best of my knowledge and understanding.
• 3&7
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 can be found at
www.mAaL.gov/oca Information on the Construction Supervisor License can be found at www.mass. o"M s
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"