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10 ABBOTT ST - BPA-13-601 o n t� The Commonwealth of Massachusetts CITY OF �) Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR SALEM Revised Alar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling "Chis Section For Official UsePolly Building Permit Number: Date d Building Official(Print Name) Signature- Date SECTION I: SI E INFO N 1.1 Propert Address: (( 1.2 ors Map & Parcel Numbers 1.l a Is this an accepted street?yes_ no tyjWNumber 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 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ S> CTION 2:; PROPERTY OWNERSHD7t' 2.1 wnert of Rgcord: MeV-,AnkASheAl 4tem /)f(A 0 Name(Print) City,State,21P I o AUAS L qT e) No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK='(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': e M SECTION 4: ESTINLkTED CONSTRUCTION COSTS [tem Estimated Costs: Official Use Only,.; Labor and Materials I. Building 3 1. Buildipg Permit Fee: $ Indicate how fee is determined: Electrical S ❑ Standard City/Town Application Fee 2. ❑Total Project Cost'. ,(lteffi x multiplier x 3. Plumbing S 1 Other Fees:'$ 1. Mechanical (HVAC) S List: 5. Mechanical (Fire $ Su ression) Total All Fees: S Check No. Check Amount: Cash rAmount 6. Total Project Cost: S S�0t7-UO ❑Paid in Full Cl Outstanding 13alance Due: � Fkj-1:�> �T 0� SECTION 5: CONSTRUC'T'ION SERVICES 5.1 Construction Supervisor License (CSL) O 7-77� U License Number Expiration Date Name of CSL H01der List CSL Type(see below) S Type _ Description No. and Street /�/� U Unrestricted(Buildings u to 35,000 cu. ft.) / `I� © /9-vy R Restricted 1&2 Family Dwellin City/Town, State, L[P M Masonry RC Roofing Covering WS Window and Siding SP Solid F'e Burning Appliances & Y1 — I Insulation Telephone Email address D Demolition 5.2 Registered Hone Improvement Contractor(HIC) IIIC Registration Number Expiration Date IIIC Company Name or IIIC Registrant Name No. and Street Email address 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 ...........0 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 to act on my behalf, in all matters relative to work authorized by this building permit application. 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 it, this app)ica t%"' is tr�ccurate to the best of my knowledge and understanding. PrintOwnerr'sforr Autl�.cut's Naune(Elec(I Oil ic 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. I42A. Other important information on the HIC Program can be found at www.mass,eov%ora Information on the Construction Supervisor License can be found at www.mass.gL) ` L 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 oftlreplaces_ _ Number of bedrooms _ Number of bathrooms Number of halt/batlu Type of heating systrm -- __ Number of decks/porches T}peorcoolingsyslem —.— L:nclosed_ - ---- ----Open -- . Tot.rl I ni'ect Sr1 u:tre PooleiimY,, " be substituted rorI_ot:tl Project Cost" - ' l �