11 ABBOTT ST - BPA-11-660 ROOFING The conunomve:dth of Massachusetts CITY
Board of Building Regulations and Standards OF SALEM
Massachusetts State Building Code, 730 C'MR. Th edition H ,•is�•dJ,um„n
1,
Building Permit Application To Construct; Repair, Renovate Or Demolish a 2008
On -or Two-Ft nily Dwelling
T is Secti For Official Use Onl
Building Permit Number: Date Applied: r
Signature:
` Building mmissione Ins or of Buildings; Date
SECTION I:SITE INFORMATION
1.1 Psoperp�.�ddj� S1.2 Assessors Map& Parcel Numbers
��-b b Ma Number Parcel Number
L l a[;this an accepted street?yes_ no
v
1.3 Zoning Information: 1.4 Property Dimensions:
Lot Area(s Ill Frontage(It)
Zoning District Proposed USC q
1.5 Building Setbacks(It)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L e.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if Xcs13
SECTION 2: PROPERTY OWNERSHIP'
2.1 ner of Record:
Name(Print) Address for Service:
signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ I Other ❑ specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
r.� I. Building Permit Fee:$ Indicate now fee is determined:
I. Building S 7 �-5-0 ❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5.Suppression)Meesion) (Fire S Total All Fees:$
u� Check No. _Check Amount: Cash Amount:_
6.Total Project Cost: S 7 7j ❑Paid in Full ❑Outstanding Balance Due:
d
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 0 1b9% G7
&(.cto'3"Pn 11 License Number Pxpiration hale
Name ut'CSL• IulJer
,`5 /l, �(JT,.,, S y A I.i t CSL 1'1 pe(see below)
Add N no I Description
Il 1 Unrestricted(tip to 35,000 Cu.Ft.)
Signature R I Restricted l&2 Family Dwelling
NI I Nlasonry Only
RC Residential R,WhO C'o%erin
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
U Residential Demolition
3.2 Re,Kist rep dHomprgxgm'entCo)ntractor(HIC)
I IIC'��m�any N• ne or lit ' egislrant Name Registration Number
ADD Address
Expiration Dale
Signature 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 ..........S No...........O
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 U y i^,..el to act on my behalf,in all matters
relative to work authorized by this building permit application..
9/37//>
3ig uture of Owner Date
l�,� /,�SSECTION7bb:OWNERt OR AUTHORIZED AGENT DECLARATION '
1, - — 44-,-' A6sb-• /O`e L ,as Owner or Authorized Agent hereby declare
that the statements and information on thing application are true and accurate,to the best of my knowledge and '.
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of r'u
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistcrcd contractor
(not registered in the Home Improvement Contractor(HIC)Program), will agJ have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program anti
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I IO.R6 and I IO.R5, respectively.
2. When substantial work is planned,provide the information below:
Total Moors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Ilabitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half baths
Typc of heating system Number oFJecks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted lift"Total Project Cost"