B-19-227 - 0010 AMERICAN WAY - Building Permit 2S GK 15 2-7 3
_M I M
The Commonwealth of Massachusetts=
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 C _ SALEM
.1,�IAR 6 P 2Re25ed 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 Applied:
q Building Official(Print Name). Si a Date
SECTION l:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
0 me rILAP-7
l.l a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: U 1 p 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 Owner'of Record:
GrlxiarrG akar�A ��6y►
Name(Print) J �- 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 pecify:
Brief Descript' n of Proposed World:
l� CP/lw F s
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ _!3 GO 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: _
5.Mechanical (Fire $
Su ression Total All Fees: $
CheckNo.(5 7 Check Amount: Cash Amount:
6.Total Project Cost: [$5300. ❑Paid in Full ❑Outstanding Balance Due:
34 (" R A I l,Gp t N S-A S9--
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL).
9797 2 Z6
License Number Expiration Date
Name of CSL Holder U
List CSL Type(see below)
Eric W. Palm
No.and Street inuton St Type Description
Salem, MA 01970 U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 FamilyDwelling
City/Town,State,ZIP M Masonry
RC Roofmg Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
l vl I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) /
�/ _ /z 20
HIC Registration Number Expiration Date
HIC Company awe r" eg strant ame
I( a erson�yenye
No.and Street Salem;MA 01970 Email address
City/Town,State,ZIP Telepbone
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 a of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize 'PCt 1h,_1
to act on my behalf,in all matters relative to work authorized by this building permit application.
u&4 Y I. 3/
Print Owner's Name(Electronic Si e) 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 application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Autflofized ge is Name-771Mnic 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.mg L og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dpss
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"