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B-17-553 - 0004 ANDOVER STREET - Building Permit Ki �C) S The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF .Massachusetts State Building Code,780 CMR SALEM Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a l" l One-or Two-Family Dwelling - ;. Thts ©H F4r.0ITic Use On - '' Miildmg Pertrttt 1 Iurtrlaer:,. bats A .I w1d o ,a1(Pt name) tge CTIO1`1:1' SITE INPQ:�MATION 1.1�Pr�rtydress: 1.2 Assessors Map&Parcel Numbers l.la 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(8) 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? Check if yes❑ Municipal❑ On site disposal system El SECTION 2: PROFRTY OArNERIIIP ' 2.1 Owner'of Record: Name t)LiA .), iCity,State,ZIP ro, No.and Street, Telephoile Email Address SECTION 3>DESCRIPTION OF PROPOSED WORK'(check 4that apply) t New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Erl Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Num er of Units Other ❑ Specify: Brief Description of Proposed Work': , y SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials Dual Use Only 1.Building $ 22 0 1. Bulling Permit Fee.$% ::.Tnclacate how ke is detersnir3ed 2.Electrical $ 13 Standard Cttyft own A pllcat on Fee D Tom Prgeet Costa(Itetit k m4ltrpher x. 3.Plumbing $ 2. Other Fees: 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Su ression) $ Total All Pees:$ Check No. Check Amount: Casa Amount:. 6.Total Project Cost: $ 2 zf oc o 0 Paid in Full O Outstanding. Ba ante Due SECTIONS: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) t-J(JA License Niunber Expiration Date Name of CSL Holder List CSL Type(see below) 1(o0 i./c�Fs�y✓c Z Tye Description ._ No.and Street UA Unrestricted.(Buildings u 'to 35,000 w.It. r�v1 R Restricted I&2 Famil Dwelling City/fuwn,State,ZIP M Masonly RC Roaring Covering WS Window and Siding SF Solid Fuel Burning Appliances �D$-j5--21— 1 Insulation Telephone Email address D Demolition r 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date tI1C Company Name or HIC Registrant Name No.and Street Email address City/Town, State ZIP Telephone SECTION 6:WORKERS'.CONIPENSATION INSURANCE AFFIDAVIT(M:C L e.152.�25C(l�}. 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..........0 No...........O SECTION 7n:OWNER AUTHORIZATIOPITO BE.COMPLETED.WHEN!. OWNER'S AGENT OR CONTRACTORAPPLIES FOIE BUILDING PERdII'G= I,as Owner of the subject property,hereby authorize - t9 act on my behalf,in all matters relative to work authorized by this building permit application. At,3 pt:-J r*6',vG.fir\ 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 contained in this application is true and accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: I. An Owner who obtains a building permit to Jo his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program);will nu have accessto the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at %v%v%v.mass.eov.'oca Information on the Construction Supervisor License can be Ibund at vvww.mass.,_,yv/dgS . 2. When substantial work is planned,provide the information below: "total floor area(sq.R.) "� (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 coolin,system Enclosed Open ]. "Total Project Square Foota,e"may be substituted fur"Tutal Project Cost"