B-17-927 - 0035 BRITTANIA CIRCLE - Building Permit 2 C,K_
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards
SALEM
Massachusetts State Building Code, 780 CNIR
� Revised Mar_1
Ol l
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
NThis Section For Official Use Only
c — Building Permit Number: Date Applc&
Building Official(Print Name) Signature Dom;
SECTION 1:SITE INFORMATION y
1.1 Property A` ddrem L2 Assessors Map& Parcel Numbers �
1.la Is this an accepted street`'yes no Map Number Parcel Number
L3 Zoning Information: 1.4 Property Dimensions:
I Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
i 1.5 Building Setbacks(ft) a
Front Yard Side Yards Rear Yard
i Required Provided Required Provided Required Provided
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L6 Water Supply: (�I.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' Ree d:
Name(Print) City,State.ZI
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'-(check all that apply)
I New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units 9-ther ❑ Specify:
i Brief Description of Proposed Work: "
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SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
j I. Building $ L Building Permit Fee:$ ;� Indicate how fee is determined:
❑Standard City/Town Application Fee
3. Electrical $
❑Total Project Costa(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
3. Mechanical (Fire $Suppression)— Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
tLicense Num be���— E.rpi tin ate
Name of CSL I of er
List CSL Type(see below)
No.and Street Type Description
I �� U Unrestricted(Buildings u to 35,000 cu.ft.)
— � R Restricted l&?Family Dwelling
j City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
pp� SF Solid Fuel Burning:Appliances
i �CJ`L /i 1 Insulation
Telephone Email address D Demolition
5.2 Re;istered Ho a[mpr ent Contractor(RIC)
i HIC Registration Numb er Exp do ate
HIC Co�p .V' ne� �egistrant i ame
No.an reet Email address
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Ci /Town,State,ZIP Tele hone
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
i this affidavit will result in the denial of the Issuance of uilding permit.
Sighed Affidavit Attached? Yes .......... No...........0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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I,as Owner of the subject property, hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
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Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
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By entering y ame belo ,I hereby attest under the pains and penalties of perjury that all of the information
i contained i this ap cati is and accurate,to the best of my knowledge and understanding.
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Print r' or: u";o zed Agent's Name(Electronic Signature) Date
NOTES:
I1. 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
I+ progiam or guaranty fund under M.G.L.c. 1.42A.Other important information on the HIC Program can be found at
www.mass.gov,oca Information on the Construction Supervisor License can be found at ww-,,v.mass.gov dps
i ?. When substantial work is planned,provide the information below:
Total door area(sq. ft.) (including garage, finished basementiattics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
f Number of bathrooms Number of haWbaths
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"