22 ABORN ST - BPA-11-292 ROOF The Commonwealth of Massachusetts
Board of Building Regulations and Standards OF SALEM
CITY
Massachusetts State Building Code, 780 CMR, 7"edition Revised January
Building Permit Application To Construct, Repair,Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
r ThisA'echpn For O ial Use Only
Building Permit N her: to Applied:
Signature:
Building Commissioner/Inspector of B LIV
s Date
SECTIO 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
��i�rl� S� .
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?
Public�� Private❑ Check if yesG]/' Municipal GyAmSte disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
/�SSos Sot s- .Zit rH
e(Print) Address for Service:
ignature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of ProposedWorkz: reroa-r
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item (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 Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $g
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees: $
Suppression)
� Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 1 b 0 Paid in Full ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 9 9 y9&
11
_ t z/].r k— M a Gh7 a de License Number Expiration Date
Name of CSL-Holder L(
/V ";&i/ List CSL Type(see below)
Address Type Descri tion
U Unrestricted(up to 35,000 Cu.Ft.)
y R Restricted 1&2 Family Dwelling
Signature M MasonryOnly
9 7 �0 RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
X x"n;L✓ V z ere— r !2t C
HIC Company Name or HIC Registrant Name Registration Number
_ r-k- oi/L �f �a
Addres /
OGI 9? Expiration Date
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 ..........13--� No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, u l i SSa—r SOU SO as Owner of the subject property hereby
authorize ht,n.- l2 ".Q CA-;L C4 to act on my behalf,in all matters
relative to work authorized by this building permit application.
dnl�dd —/O
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I, �n Q r /,,— "ac-14 a 4 ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. ^
"Caen Cd
Print Name
d9 -a1 —/e
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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(I-IC)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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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 halUbaths
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"
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CdMl- CERTIFICATE OF LIABILITY INSURANCE 8/4/�)
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PRODUCER THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIG TS UPON THE CERTIFICATE
C. A. POTTERS INSVRANCS. AGBNCy HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR
233 NORTH II�LIN STREET ALTER THE COVERAGE AFFORDED 6Y THE POLICIES FIELOW.
RAMOLPE, DNA 02368 INSURERS AFFORDING COVERAGE
INSURED MACHADO, DDARTE !NSUWRA- -
INSUaER B
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ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY 8E ISSUED OR
MAY PERTAIN.THE GISURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
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