B-17-919 - 0007 VALE STREET - Building Permit Board of Building Regulations and Standards S ZS l b$ql l j
Massachusetts State Building Code, 780 CMR, 7t' edition OF SALEM
Revised January
Building Permit Application To Construct, Repair,Renovate Or De isl lE-0 4 2008
One- or Two-Family Ahvelling � 'w' fi
Section For'Official Use Only a � ;
-Bbildir►g Permft,Number. Date Applied.
z
.,
Build7ng Commissioner/;Inspector of-Buildings 77,
. Date
".
s SECTION 1 SITE INFORMATION
1Fy
1.1 Pro ertv Address: 1.2 Assessors Map &Parcel.Numbers
OQR 76
l.l a is this an accepted street?yes Z 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 Ruilding Setbacks(ft)
Front Yard Side.Yacds _ 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 G Private❑ Zone.: 'Outsider_ Flood Zone?
Check if yesO Municipal ❑ On site disposal system ❑
SECTION 2 PROPERTYOWNERSHIP'
2.1 Owner'of Record.
Name(Prim) A dress for Service:-
Signature Telephone
SECTIO N 3..DESCRIPTI0N OF PROPOSED WORKz'check alt that a 1
.( Pp Y)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ > Addition. 0
Demolition ❑ Accessory Bldg. ❑ Number of Units Other O Specify:
Brief Description of Proposed Work2: Rp b u., Id 012 n-, n e 4 CX m�-�P �o�)i n e
SECTION 4 ESTIMATED�CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials) Official Use Only
l.Building $ 1 Building Permit Fee $ Indieate how fee is detexnmed
3k4 50. ov x.
2. Electrical
C7 Standard Crty/To'.wn Appltcataon Fee
fl Total.Project Cost."(Item 6)x multiplier x
3-Plumbing $ 2 Otlier Fees: $
.� .
4. Mechanical (HVAC) $
S.Mechanical (Fire
Suppression $ Total All Fees $
Checot Check Amount Cash Amount
k N
6. Total Project Cost: $ 3�i SD 0(�
. _.-.. ... . _ . f—' - --- _ w..,w -
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration
iration Date
N eofClH)
older
C �.Q f L st:CSL Type(see below) (�
Address T Descn ton - } i
U Unrestricted(u' to 35,000 Cu.Ft:)
Signature R Restricted 1&2Famil Dwellin
M Masonry Only
Telephone RC Residential.Roofin Coverin
WS Residential Window and Siding
SF Residential Solid Fuel Burning.Appliance-Installation
D Residential Demolition
5.2 Registe ed HomImprovement Contractor($IC) y 2
g
HIC Compare Name or HIC Regotr t Name Registration Number
Address a 12 1 r 7
��� _ `�"JOOJ Expiration Date
Signature Telephone
SECTION 6 WQRKER-S COMPENSATION INSURANCE AFFIDAUX T' A
(1VI GL c �'S2 23C 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 ....
.;_.. p
.
SECY`TION'7a OWNER AUTHORIZATION TO BE COlV[PLETED WIZEN
OWNER'S"AGENT QR CONTRACTOR APPI;IES FOR.BUILDING PERMIT
: ,.
i' as Owner of the subject property-hereby
authorize to act on my behalf,in all matters
relative to work authorized by this bu` ing perm i applicati n.
ignature of Owner Date
SECTION 7b OWNER' OR:AUTH01ltIZED AGENT;DECLARATION..
-� ` as Owner orAuthorized Agent hereby declare
that the statements and information on the foregoingapplication,are true and accurate;to the best of my knowledge and
behalf:
a- S h
Print Name
Signature of'Owner or Authorized Agent
Date
(Signed under the pains and penalties of perjury',
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(IIIC)Program), wil l not have access to the arbitration
program or guaranty fund under M..G.L. c. 142A. Other important information on the HIC Program and
Construction.Supervisor Licensing.(CSL) can be found in 780 CMR Regulations l'l O.R6 and l I ORS,respectively
2. When substantial work is planned,provide the information below:
Total floors area(Sq..Ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Habitable room'count
Number of fire laces
p Number of bedrooms
Number of bathrooms. Number of half/baths,
Type of heating system,, Number of decks/porches
Type of cooling system. Enclosed Open