B-19-205 - 0000 BAKERS ISLAND - Building Permit Ak �S
u � The Commonv;e:-alth of Massachusetts —
��`�• Board of Building Regulations and.Standar,Js, CITY OF
Massachusetts State Building Code, 7$0 C`�t13.
SAL]EM
Rei i s.ed,Mar 2.011
Building flcrhiit Applk ation'Co Construct,Repair,Renovate;Or Demolish a
'n One-or Tti�o--f'tmily Dwelling
uo' This Section For Official Use Only
Building Permit Number: -_4—_--- - Date Applied: -
�V Sf,��E • . --_sus —. - 3 /9
—13uildingOffcia (Print Name) _ Signature -- -- Date
_ SECTION I:SITE INFORMATI9J N1
J..1 Property Address: --- - --- 1.2 Assessors Malai die Parcel Numbers -_---
L l a ls'this an accepted street?yes. no Map Number Parcel Number
L•3 Zoning;Information: 1.4 :Property Dimensions:
0 3 o -- - I° ----—
Zoning District Proposed Use — Lot Area(sq ft) Frontage(ft).
1.5 Buildirg Setbacks(ft) -- —
Front Yard Side Yards � Rear Yard
--- Required E
]'rovided Required— Provided - —Required — ---Provided ---
1.6 Water Supply:(M.GJ.,c..40,§54) 1.7 Flood Zone Information: - 1.8 Sewage Disposal Su%stem:
Zone: _ Outside Flood Zone? '
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
_ SECTION 2: PROPERTY OWNERSIH111"
2.:1 Owner'of Record:
7LN4rlA ,j i-Fwbc I�C�s,1.66 -N D A N bSA3-1.._: A1_� 0 �'�o -_..----
Name(Print) City,State,ZIP r.. —
No.and StreEa Telephone Email Address
SECTHOIN 3: DESCRI:PTION rt:3 F PROPOSED WORIK ,( heck all that aipply) -
New Construct:iong 14.isting Building ONvries-Occupied ❑ Repair ( 9 ❑ Alteration(s) E_I JAddition ❑
Demolition Al A4,cessory Bldg.IN Number of Unit Other ❑ Specify:_—
I3rief Description of Proposed Work2:`� _..... _
_....� x SST I7JtT I_ox L�__._�,sTTI �_y 3 ray
SAS SI— hWA _0N
Y-1
SECTION 4: ESTI11,1,,kTED CCONSTRUCTIll[M COSTS,
Estimated Costs:
]:tern Official Use Only r;i
_.. _(Labor and Materials}
1. Building $ >0���� �� L. Building Perrni Fee 6 Indicate how iee is determined'-
?.Electrical g_ ID Standard (.,ity/Town 'tl:rplication,Fee i -
--- --- -.-_--- ---_ '1-1 Total Project Costa It urn 6)x multiplier X 2D
3 Plumbing; $ ?. Other Fees: $
4. Mechanical (HVAC) }; _ l i:st: --- -- - --
5. .Mechanical (Fire
ression,) Total All Fees: $___.._. .
_-- —__ —_ Check No. Check Amount: - Cash i),rnount:. -
6. Total Project Cost. 1 1 O ooc�•tea --- ----.Cash
Paid to Full I 1 Outstanding Balance Dii.ie
9V1n.t�.� Tb �(�C1�5Ebv2� N �
SECTION 5: (i'0114STRUCT"ION SER1v''I"ES
5.:1 Construction Superldsor License(CSL)
- i ne -- — ------ .
License Nai:rcber Fxpiratio•n Date
Na--ane of CSI.H--older
List CSL Type(see below)
---- -----..._._---- ---. __.._......---- Type
No.and Street Description_
U unrestricted(Buildings uli to 35,000 cut.ft.)
Restricted 1&2 Family I i elling---
cirwrown,State,7_If _ :M Masonry --��
RC Roofinovering
WS Window and Siding
SF -solid Fuel Burning Applianc s
I Insulation
Tele hp one -- Email address _-- D - Demolition ---_
.`S.I. Registered home Irrnparovement:Contractor(FlIC)
H:II.0 Registration Number Expiration Date
t-IIC Company Name or HI L F,-zgistrant Name
No. and Street ------- F,mail addre,,
City/Town,State,ZIP telephone
SEC'1f:ION 6:W01ltK,ERS'COM.PENSA'r:l[ON INSURANCE AFIFIlDiMT(M.G.L.c. 152, ?4' 25C(6))
'Norkers Campensation Insurance affidavit must be cornpleted.and submitted with this application. Failure to provide
this affidavit will result:in.the denial of the Issuance of the building pertnit.
Sig ned Affidavit Attached? Yes .......... ❑ No........... El
-- SECT10N 7a: OWNER AUITI 0RIZATION TO BE C'OPaIPLETED WHEN _
OWNER'S AGIENT OR CONI'PLACTOR APPLIES FORIEoUCL:DTNG PERMIT
T,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work aua orized by this building permit application.
Print Owner's Name{Electronic Signature]
--._._......�--—
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I33, entering my name below, l hereby attest under the pains and penalties of perqury that all of the infornna.ion.
c.or►tained in this application is true and accurate to the best of my knowledge and understanding.
l'ri.nt Owner's or Authorized r,;nent's Name{Electronic signature} Date
MOTES:
I. An Owner who obtains a building;permit to do his/her own wort.;,or an o°gin ner who hires an unregi::.tered contractor
(not registered in the 13:ome ImprtPvement Contractor(HIQ Program), u'll riot have access to the arbitration
program or guaranty,fund under 1.4.G.L.C. 142-1.Other important infornation on,the:IIIC Program.cart be found at
vvww.mass. ov/oca Information on the Construction Supervisor License can be found at www.mass.ggy/dps
2. When substantial work is planned,•provide the information below:
roi:al floor area(sq.ft.) (including g__ —__ _ arage,finished basernent/attics,decks or porch j
Gross living area(sq.ft.)."
— Ilabitab➢a 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_ _ —
'.i. "Total 11'reject Square,.Footage"may be substituted for"Total Project Cost"