B-19-475 - 0057 VALLEY STREET - Building Permit 3S cK l 3 3
The Commonwealth of Massachusetts CITY OF
` Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For Official Use Only,
1 Building Permit Number: Date Applied:
Building Official(Print Name) Signa DDaW
SECTION 1:SITE INFORMATION r
1 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers ".
r� 1.1 a Is this an accepted street`'yesno Map Number Parcel Number �f
1..3 Zoning Information: 1.4 Property Dimensions:
(� Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1-� 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,g 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 R ord:
Name(Print) City,State,ZIP
57 VccltPy :5oC-_
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
r f� Descriptiotl of Proposed Work 2:
a�12Q.11i on
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1. Building S 4 14 (,t l. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing S 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire
Su cession) S Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ "l�` ! 0paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5. Construction S ervisor License(CSL) /�C 09L4
License Number Expiration bate
Name of CSL Holder r
as Saw Sust_ List CSL Type(see below) y�
No.and Street d.C�— r� Type Description
R Unrestricted(Buildings u cu.ft.)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 Lbey% D I Demolition
5.2 Registered Home Improvem t Contractoi HIC) M b t 5 q
HIC Registration Number —Expiration Date
HIC pany ame HIC Regikt&nt Name
vs .
and Street ' n� �D� Email address Cbe^
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 ..........-0 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 �I in�OfYI�Q. Ch1�U ��) va
to act on my behalf,in all matters relative to work authorized by this building permit appltcation.
yleen Rr,4rrxfh sl2/! L
Print Owner's Name( lectronic 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 applicat i true to to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic ignature) — � 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.iov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
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"
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