B-17-1043 - 0006 ADAMS STREET - Building Permit The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY M
Massachusetts State Building Code,780 CMR �
Reviseedd Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Ap d:
3/
Building Official(Print Name) Signature Date
® SECTION l:SITE INFORMATION
1.1 Property Ad ress: 1.2 Assessors Map&Parcel Numbers
Aqd gain
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~( 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 wner'of Re r : G //
0Gt Yl W�V)y7 v$ _3a l-e f'17
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other Specify:M n 4-v-5
Brief Description of Proposed Workz:
h4fall No ►-►�,. C QSSSZ Gy c..�S
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
' 1.Building $ avd 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: r7
5.Mechanical (Fire $ -
Suppression) Total All Fees:$
Check No.L j6—Check Amount: Cash Amount:
6.Total Project Cost: $/,A 00, ❑paid in Full 0 Outstanding Balance Due:
`� I M Alt_L-eyD N SAsts
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
�379"7 "7 q/23 k
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) U
Eric W. Palm
to Type Description
No.and Street
n St
Salem9 MA 019.0 U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwellin
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)
HIC Registration Number Expiration Date
HIC Company a e r C eg' trant ame
01 r,fie erson t ve>oue
No.and Street Saltlfi 1A 0.1970 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 Issuanc of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION lac OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize F/I i G P&/N'l
to act on my behalf,in all matters relative to work authorized by this building permit application.
a JO�Zy
Print Owner's Name(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* this application true and accurate to the best of my knowledge and understanding.
Print Owner's br 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.mmEgov/oca Information on the Construction Supervisor License can be found at www.mass.goy/dps
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"