2 ADAMS ST - BUILDING INSPECTION (2) The Commonwealth of M ssachusetts
�3 }� Board of Building Regulations and Standards CITY
t!y ) Massachusetts State Building Code, 780 CMR, 71h edition OF SALEM
"'www;;✓✓ Revised Junuury
Building Permit Application To Construct,Repair, Renovate Or Demolish a 1. :00
One-or Two-Family Dwelling
This Section For Official Use Only
• Building Permit Numb le pplied:
Signature: "/t-f r^'79 140 14
Building Commissioner/Inspector of Buildings ate
SECTION 1:Sot INFORMATION
1.1 Pro erty Address: L 1.2 Assessors Map& Parcel Numbers
Z A-A{ kvvt.S s 'i 54( Lt
I.I a Is this an accepted street? rs)oC no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(R)
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 yesO Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
��ul GI J Ct, A/o Cc- D 44, s 7-
Name(Print) Address for Service:
ivy � y3 �
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.Cl Number of Unis Other ❑ Specify: )LJSU�Ar/D / i
Brief Description of Proposed Work'':
li✓SaL 6110k) ( r✓ /NJ Cc-LLCJLasv
1lapLdL LI G vrinr c I 1) dR. 4` A ::2 1244c-4df, wtwi
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
J. Mechanical (HVAC) S List:
E
hanical (Fire S
ssion Total All Fees:S
Q Check No. Check Amount: Cash Amount:l Project Cost: S q.261-v q 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 'O) 3-2Q 1/- 2-7-2 1/
SS-C SJ9 �-/,,t`.n S l.iccnw Number Expiration Date
Name of C'SL-I(older /O List CSL'type(see below) U
S Description
:\JJ ss U UnresiricteJ u to 35.11O)Cu.Ft.
R Restricted 1&2 Family Dwellin
Si atu M Masonry Only
4,2 /�o - 2 3,3 RC Residential Roofing Covering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) 163106
A�,�R(c.4yj ZU'LoIW_Cz�EGt111nLo (irt LCG
I IIC Company ante or tt1C Registrant Namf9 Registration Number
Z Ai �o w - F(7
Z 3 3 2;901/ Expinition Date
s ore 7�1 Telephone
Sign
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 2SC(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.........4 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 to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signal 7
i alure fOwner Date
ECTION 7b:OWNER(OR AUTHORIZED AGENT DECLARATION
1 as Owner or Authorized Agent hereby declare
that statethe foregoing application are true and accurate,to the best of my knowledge and
alf. �aandformation on
Print Name
�- ZC� - 70/0
Signature of Owner or Authorized Agent Date
Si ed unJer the sins and nalties of i u
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(HIC)Program),will&of have access to the arbitration
program or guaranty fund under M.G.L.c. 1 d2A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IOAS,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 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"