B-19-243 - 0071 VALLEY STREET - Building PermitI
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
0 Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
q� One-or Two-Family Dwelling
�J
This Section For Official-iJse'Only,=
Buildin Permit Number:` Date Applied
r� Building Official(Pont Name) Signature Date
SECTION 1 SITE:INFQRMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1 V�Ik4 .54
1.1 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 Food Zone Information: 1.8 Sewage Disposal System:
Public L�J J Zone: Outside Flood Zone?Check❑ Check if yes&K Municipal Von site disposal system .
SECTION 2: PROPERTY OWNERSIiIPi
2.1 Owner'of Record: +
►-&'shm .S,4/e.n In,4 O/9 7c)
Name(Print) City,State,ZIP
Vc,lle<, S-f- q''3-4',}1-o v'm;s(ee-t-4 to Z'ce,ir`
No.and Street Telephone Email Address rrg
C!?.
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SECTION 3.DESCRIPTION:OF PROPOSED WORIC2 check all that a Iv �_ '�
. . : PP ) 4, . .
New Construction❑ Existing Building❑ Owner-Occupied 61 Repairs(s) Gr Alteration(s) 91� Addition ❑
` Fl1
Demolition ❑ Accessory Bldg.❑ Number of Units J Other ❑ Specify: �•,,.
Brief Description of Proposed Work': '3, oe'7f (1e4rijel Me+*.Q -rrume %Qsw/41e 6reea 8. d-,4 w4//�
l{r d drag ceii,m he,7hi— w-11 u2 C Ala Alf mill l" h all {G,hene_Ae yi+*) Smyr ond
C,,&,ek AID_'SAEx . 2e.QIaue P_rv,ii' .<nndo-a>s ct'd 4a „ VOL
de Mee re 1 o(eme-q NO q0
SECTION 4:_-ESTIMATED`CONSTRUCTIO NCI
STS
—_ __Item Estimated Costs Offie�aLUse Only
Y
(Labor and-MatenaIS)
1.Building $ a S Ood 1 Buildmg Permit Fee:$ Indicate how:fee_is determined:
0 Standard City/Town Application Fee
2.Electrical $ Soo
0 Total Project Costa(Item 6)x multipher.5 x
3. Plumbing $ S oc�a 2 Other Fees $ " `
4.Mechanical (HVAC)
5. Mechanical (Fire
Suppression) $ Total All Fees .$
Check No Check Arnounf Cash Amount
6.Total Project Cost: 000 O Paid in Full 0 Outstanding Balance Dtie
Y
SECTION 5:"CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
cs-1 I 1 T610 os aoa I
M�Ghuei T-�jPiGCS License Number E irati nDate
`l Name of CSL Holder
List CSL Type(see below) 0
No.and Street Type Description
Per' m 6 ott U Unrestricted(Buildings u ft to 35,000 cu. .)
��P� C�� R Restricted 1&2 FamilyDwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
61-7-90LI-80a Mi14PiCC4, 9'.9rnCE I Insulation
Telephone Email address D Demolition ,
5.2 Registered Home Improvement Contractor(HIC) y0 SAS 3 3 7 0�
Mtr-6p,l — P.,ecc, HIC Registration Number Expfration Date
HIIrC Company Name or HIC Registrant Name
IOM�6,
dr. fy6iclpicc 41Y744iflYY7.
o.and Street E ail address
HW&e)4 . MA a[16o
Ci /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 M 06,e I J U)-�c C cA
to act on my behalf,in all matters relative to work authorized by this building permit application.
Lv,Y-0,N)mA ii koilwcyVcn S�f r�mc,� dd•� 31sI)
Print Owner's Name(Electronic Signature) ��Date
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.
Print Owners 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.gov/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"
I
LAKSHMI
71 VALLEY STREET
` SALEM MA. 01970
TEL:- 443 921 6850
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