B-19-9 - 0038 UPHAM STREET - Building Permit CL<— 10 5,z;-
I C> (0 S :z
The Commonwealth of Massachusetts '-7 -7
b a�1 CITY OF
Board of Building Regulations and Standards
9
SALEM -
Massachusetts State Building Code, 780 CMR
Revised Mar 2011
Building Permit Application To Construct,Repair, Renovate Or DemOliih JAIN 3 P
One-or Two-Family Dwelling
This Section For Official Use Only
Building Pen-nit Number: )ate Applied:
Signature
Building Official Print Name) �igna� Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
38 Upham St.,Salem 01970 25009C 009C
Lla Is this an accepted street?yes-->(— no Map Number- Parcel Number
.1.3 Zoning Information: .1.4 Property Dimensions:
— residential 5,826' 50.25'
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 0 Zone: Outside Flood Zone'?.
Check if X Xon site disposal system 0
y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Polly Kienle il) Lexington,MA 02421
Name(Print) City,State,ZIP
18 Eliot Rd 781 862-2385 PollyKienle@hotmail.com
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
Construction 0 t
NewF. I Existin-BuildingX Owner-Occupied)O Repairs(s) Addition 0
Demolition 0 1 Accessory Bldg. 0 Number of Units- I Other 0 Specify:
Brief Description o Work2.f Proposed Replace cabinets.Install new counter tops.Lay new floor.Enlarge,Windows.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item m Estiated Costs:
(Labor and Materials Official Use Only.
n
1. Building S1.000(L)+10,000(M)=$1J,00 I. Building Permit Fee: $ Indicate how fee is determined:
y 0 Standard City/Town Application Fee
co
2.Electrical $(already complete) n T t.
CoSt3
0 Total Project (Item 6)x multiplier X
3. Plumbing $(none necessary) 2. Other Fees- $
4. Mechanical (HVAC) $(none necessary) List:
5.Mechanical (Fire
Suppression) $(none necessary) Total All Fees: $
6.Total Project Cost: $ 11,000 Check No. Check Amount: Cash Amount:
0 Paid in Full 0 Outstanding Balance Due:
1,0
•� SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
NA License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu. ft.)
R Restricted 1&2 FamilyDwelling
City/Town,State,ZIP M Mason
ry
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(H.1C)
NA HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant
No.and Street Email address
Cii /Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 1.52.§ 25C(6))
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 .......... ❑ No ...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR.BUILDING PERMIT
I,as Owner of the subject property,hereby authorize NA
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print O er's Name(Electronic S nature Date
i
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.
Polly Kienle / / i1 // _ 12/21/2018
Print Owner's or Authorize gent's 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(HIC).Program),will not have access to the arbitration
program or guaranty fund under M.G.L.e. 142A.Other important information on the HIC Program can be found at
www.rnass.Tov%oca Information on the Construction Supervisor License can be found at www.mass.Roy/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/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
The Commonwealth of Massachusetts CITY OF
' Board of Building Regulations and Standards 5ALEM
Sill. ' Massachusetts State Building Code, 780 CMR
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
38 Upham St.,Salem 01970 25009C 04/9C
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
residential 5,826- 60.25'
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? MunicipalOn site disposal system ❑
Check if yes
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Polly Kienle Lexington,MA 02421
Name(Print) City,State,ZIP
18 Eliot Rd 781 862-2385 PollyKienle@hotmail.com
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building X Owner-Occupied)O Repairs(s)X I Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work2:Replace cabinets.Install new counter tops.Lay new floor.Enlarge windows.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $1,000(L)+10,000(M)=$11,000 Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $(already complete) ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $(none necessary) 2. Other Fees: $
4.Mechanical (HVAC) $(none necessary) List:
5.Mechanical (Fire
Suppression) $(none necessary) Total All Fees:.$
Check No. Check Amount: Cash Amount: "
6.Total Project Cost: $ 11,000 0 Paid in Full 0 Outstanding Balance Due:
I
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
NA License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted Buildin gs up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,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)
NA HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State ZIP Telephone
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
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize NA
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER' 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.
Polly Kienle -
12l21/2018
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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/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/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"