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B-19-478 - 0166 BRIDGE STREET - Building Permit Ct< I2Li �' 32. The Commonwealth of Massachusetts +"Mr . Board of Building Regulations and Standards ' CITY OF l SALEM Massachusetts State Building Code, 780 VWSC 16 Ikt vwsed Mar 2011 Building Permit Application To Construct, Repair,Renovate Or Demolish a One-or Two-Family Dwelling 241119 HAY _17 ►i This Section For Official Use Only Building Permit Number: Date Applied: �46A, Building Official(Print Name) Signature ef: Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 27t f5olm l 1(s& ?)Ai D(fS CT. SP((X N, MA 0 161+0 (� 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) 1.5 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: MA\ p2"ri VftalJGC 512.EM, MR , 01at40 Name(Print) City,State,ZIP 100 5�k,%Dw ST. (gJ?)0I-4t3- 224t, Rftoti0iC6C,) COMCOST No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building K Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) Addition ❑ Demolition ❑ Accessory Bldg. ❑ Nutnber of Units I Other ❑ Specify: Brief Description of Proposed Work': Si D1 n)(r REAL A[g nl`a- (j'U fii 2S P�PrGE X4E n/ SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 0 go 00 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 $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost:Is f ©m'00 ❑Paid in Full ❑ Outstanding Balance Due: b � a SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) D 83 S55 11•06. ZO To 'N. Ft LkN Q License Number Expiration Date Name of CSL Holder Z S CO►A MON v 1S P'a AVM . List CSL Type(see below) U No.and Street Type Deasenplion 1W CE5TE7M^ t O U Unrestricted Building s n to 35 000 Cu.tt. qs3 R Restricted 1&2 FamilyDwelling Citylfo State,ZIP M RC Roofmg Covering WS Windowand Siding Q SF Solid Fuel Burning Appliances 1�8 CJ.S9 ��O$ llgRl11N1� ' C4 >j�� I Iusutarion Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 1e�I '1/. 4 (X[T3 12,0 y S SI )0 IT e" e'4)Aj S'r 'u&rI Ori HIC Registration Number Expiration Date Inc i 3�Com Namc'�for 1�egistrantName F e No.1a,nd Street A \ �iLAtibt 0 A 1 011q L. (6 &a '$ro-05 Email address City,/Town,State,ZIP Tel hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(1VLGJL e.152.§25C(6)) Workers Compensation Insurance af6davitmtut be completed and submitted with this application. Failure to provide j this affidavit will result in the denial of the Issuance of the building pernrit Signed Affidavit Attached? Yes._...._../b` No.. ...❑ j SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERNIIT I,as Owner of the subject property,hereby authorize to act on my behalf,iu all matters relative to work authorized by this building permit application. I Print Owners Name(Electronic Signature) Date SECTION 7h:OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below,I y attest under the pains and penalties of perjury that all of the information containei- s applicati a and accurate to the best of my knowledge and understanding. t s or is Name(Electronic Signature) Date NOTES: I. 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(MC)Program),will not have access to the arbitration program or guaranty fund under MG-.L.c.142A.Other important information on the HIC Program can be found at www.mass.goy/oca.Information on the Construction Supervisor License can be found at wvvw.mass.gov/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/porgies Type of cooling system Enclosed Open 3. -Total Project Square Footage"maybe substituted for`Total Project Cost'