7 ABBOTT ST - BPA-14-1785 REMODEL BATH !f3- Itf -I -7gS 2 o�
The Commonwealth of Massachusetts RECEIVED
UlfBoard of Building Regulations and StandRAPECTIONAL $E VICRTY OF
Massachusetts State Building Code, 780 CMR SALEM
Revis d Mar 20[I
Building Permit Application To Construct,Repair, RenovallAr W4121.
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: ate Applied:
/41� 9/ I y
Building Official(Print Name) Signa Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
7 /�s�T�oz�' �S+
L In 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(it)
1.5 Building Setbacks(it)
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? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
2ollReuacA,fi�e TrU.n Salem MA d /9%D
Name t) City,State,ZIP
7 OIT ST
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK''(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s),W I Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work :
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:Labor and Materials Official Use Only
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $
❑ Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ ?00 2. Other Fees: $
4.Mechanical (IfVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ go O ❑Paid in Full ❑ Outstanding Balance Due:
'St--- too .P tv- -i-r) M L-k'
5EN'I- t k 1 $ -ra
CI
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) �� 2 � lG
J� License Number Ex iration Date
Name of CSL Holder
Lis
,�/1 t CSL Type(see below) U
No.an Street Type Description
-7A( Ehj / 'A O(R 7 U Unrestricted(Buildings u to 35,000 cu.ft.
`-7 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
!'/-M 1779 S78 1461 e(.g?@Co-%clI ST A/ET I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) /ofj?L
I�Q KYC&17 /A-64- HIC Registration Number Ex ration Date
HIC Co parry Name or HIC Re t Name
/K �stran
K. dmc-y � 14-�IIVL4g9@rosrCIs7-
, u T
No.and Stre t Email address
�'�1,� wl� 0/970 971� s7Y tg6'1
City/Town, State,ZIP Tele hone
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
1,as Owner of the subject property,hereby authorize %/ �7 oyx- /14fu-
to act�behalf' ll tters relative to work authorized by this building permit application.
Q AJ 2
Print Owner's Name(Electronic Signature) I Oate
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 Owner's oo d 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. c. 142A.Other important information on the HIC Program can be found at
www.mass.14ov/oc 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 haWbaths
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"