B-17-1056 - 0020 VERDON STREET - Building Permit r' The Commonwealth of Massachusettsb4, :.1 { t
.
i ;Board of Building Regulations and Standards CITY OF
SALEM
;Massachusetts State Building Code,780 C "� p `
I i � d�� 2 Revised Mar 2011
`Q + Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
_ This Section For Official Usg Only
Building Permit Number: j Date App ed)
ze6A-�
Building Official(Print Name)' Signature Date
..� SECTION 1:SITE INFORMATION
l 1.1 Property Address: 3 1.2 Assessors Map&Parcel Numbers
afl V e.razon Sf
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 q Side Yards Rear Yard
Required Provided Required Provided Required Provided
6 Wafer Supply:(MLHA
O ,l�I 0,§54) 1.7 Flood Zone Information: ' 1.8 Sewage Disposal System:
ublic O Priva
Zone: Outside Flood Zone?
l I�I te❑ — Municipal❑ On site disposal system [I Check if yes[]
SECTION 2: PROPERTY OWNERSHIP
ll� Owner of eeord
I
�,lee
��� Se l e
'Dame(Punt)pt ,f I J City,State,ZIP 7
G�NV2 Tol .�
� J1.i �D�`O ��'o3/
w7o and Street V Telephone Email Address J
I q i{ �� SECTIC�;� '3:DESCRIPTION OF PROPOSED WORK(check all that apply)
'New Construction❑ Exist, g Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Acces ory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Propose Work2:��,,1ov P P is i i n r ors , rla ;sl,
t
�r SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item 1"�
Estimated Costs: Official Use Only
i Tabor and Materials
L Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project (Item 6)x multiplier x
f' 3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total All Fees: $
? Check No. Check Amount: Cash Amount:
6.Total Project Cost: $1
006 ❑Paid in Full ❑Outstanding Balance Due:
\\ /
' II
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisory License(CSL)
i License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
i
No.and Street j Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
111i WS Window and Siding
1 SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
'5.2 Registered Home Improvement Contractor(HIC)
1!1! 11C Registration Number Expiration Date
'HIC Company Name or HIC R� istrant Name
+N eto.and Stre iyi"M
Email address
r�
i /Town,State,ZIP IIrI Telephone
J 101
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
11lWorkers 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.
,,. gym.,
jSigned Affidavit Attached? Yes .......... ❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'SMAGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
141 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.
Print Owner's Name(ElectronicSignature) Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
i
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 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.goy/des
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 1 Enclosed, Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
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