B-17-1201 - 0004 BERUBE ROAD - Building Permit The Commonwealth of M-asaGhiuse is
PI A X 0 Board of Building Regulations and Standards CITY OF
Massachusetts State Building c g MR Qf- � � SALEM
Q Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This.Section For.Official Use Ont
y
Building Permit Number: Date A p ied:
Building Official(Print Name) Signature lbat
SECTION 1:SITE`INFORMATION
1.1 Property4d s: 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: IA 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?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of cord:
VOVAI rTWj,
Name(Print) City,S ate, 1
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check a that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Erl Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ SpeciIF
fy:
Brief Description of Proposed Work2:
SECTION 4 ESTIMATED'CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building A. Building Permit Fee:$ Indicate how fee is.determined:
2.Electrical $ ❑Standard..City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier x
3.Plumbing Fees:`$
4.Mechanical (HVAC) $ List.
5.Mechanical (Fire
Suression) $ Total All Fees-
pp $
Check No. Check Amount Cash Amount
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
i '2I i� ��tt_Cp
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
t2vi-06f Of
License 1 umbeV" r"— Expi atio ate
Name of CSL HolderF.
List CSL Type(see below) �
No.and Street Type Description
U Unrestricted-(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/T, n fate,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 Exp atio D tc
HIC Com y � ant Nam
No.and SItreet T Email address
City/Town,State,ZIP ele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152.§ 25C(6))
Workers Compensation Insurance affidavit must be mpleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issu4X&of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN.
OWNER'S AGENT OWCONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize t yff 11
to act on my behalf,in all matters relative to work authorized by this building pe t application.
Print Owner's Name(Electronic Signafiire) Date
SECTION 1ti:`OWNERI 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 4ecAirate to the best of my knowledge and understanding.
IL L"V
Print Owner's or Au orized Agent's N e( ectro is Signature) a e
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.mass. 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"maybe substituted for"Total Project Cost"