26 ABBOTT ST - BPA-15-755 REMOVE CLOSET/MAKE LAUNDRY 5q 2_ Cl2
,l The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and St"O&VED SALEM
Massachusetts State Building"EMIgPP@2L SERVICES RevisedMar2011
Building Permit Application To Construct,Repair,Renovate Or Demob h a
n One-or Two-Family L 2 q -- b
U J This Section For Official Use Only
Building Permit Number: Date Applied:
(^ Building Official(Print Name) Signature Date
1 J , SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
� �� �4L,1-rdf ��'•
1.1a 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 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑ P p y
SECTION 2: PROPERTY OWNERSHIP'
Name(Print) City,State,ZIP
a6 f� �60+ 5� ( Irl d61 S 0 9
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Worrk2: - o ✓' of C ( 'F 1^
% ✓ r/IT� W t v 1
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ R 500 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ I tl ❑Total Project Cost'(Item 6)x multiplier x -
3.Plumbing $ 6 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire Suppression)
$ Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 5 S ❑Paid in Full ❑Outstanding Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) y L �
Ay d r O Cf.o f 5d License Number Expiration Date
Name of CSL Holder
1 2 List CSL Type(see below)
No.and Street TY!e - .Descripfion j
1 _J 0 U,P/ `�-S 0 S Unrestricted(Buildings u to 35,000 cu.ft.
h
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M I Masonry
RC I Roofin Coverin
WS I Window and Siding
` ,AI SF Solid Fuel Burning Appliances
V l I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvemfat Contractor(HIC)-
_ () 0 s df v 6 St ruC+;d, [ IC 6 9 ur t1-1 -y1-19
HIC Company Name or HIC Registrant Name HIC Registration Number Expiration Date
No.and Street Email address
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City/Town, State,ZIP - Telephone
SECTION 6:WORI�RS'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
OWNER'S AGENT-OR CONTRACTOR APPLIES FOR]WILDING PERMIT ' y
I,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.
ALI
Print Owner's Name(Electronic Signature) Date
SECTION 7h:OWNER'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 knowledge and understanding.
,)IP 1(ae /C'. ',o� �-a � -Is
Print Owner's or Authorized Agent's Name(El 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
wivw.mass.gov'oca Information on the Construction Supervisor License can be found at www.mnss.gov/dam
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'