11 ADAMS ST - BPA-14-568 INSULATION i
L4 � 31 33
CIA The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Building Permit Application To Construct,Repair, Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only - -
Building Permit Number: Date Applied:
I/VZfL i �J �� G 1•Z I y
BwldmgOfl (Prin[Name) - Signature - - Date
SECTION 1:SITE INFORMATION
1.1 Pro e A df ess: I 1.2 Assessors Map&Parcel Numbers
�� �Q a H7 S ST.
1.la 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:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
/Ver l Grea o SC,/-ern Oq o/ ? 7d
Name(Print)
I I � �/ City,State,ZIP
1112tarNs =Q 97Fs• zI tM791
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ teration(s) 0 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other. pecify: 7Jt-✓
Brief Descrip 'o of Proposed Work2:
-3
arir
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials y
1.Building $ i 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard -City/Town-Application Fee
El Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) Total All Fees:$
6.Total Project Cost: $ Check No. Check Amount: Cash Amount:
0 Paid in Full ❑Outstanding Balance Due:
i
SECTION.5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) g-7 9'7 ,'
a rN
License Number Expiration Date
Name of CSL Holder Eric W.Palm
List CSL Type(see below) LA
3 Hilton Str et
No.and Street Salem MA 01970 Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
Cntyfrown,State,ZIP R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window andSidin
SF Solid Fuel Burning Appliances
1 Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) L��y
1 yz0$�1 � .
HIC Company Name or HIC R p1 eat enzation,LLC HIC Registration Number Expiration Date
No.and Street
Salem AAA 0197(I Email address
Cr /Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be co eted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuanc fthe building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 73:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
rO�wnerfthe subject property,hereby authorize � 4 Cre&h
eehhQallf,,in all matters relative to work authorized by this building permit application.
ti
rntOwner's Name(Electronic _ 1b,14 h —
Date
SECTION 7b: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
c—ontained in this application is true and accurate to the best of my knowledge and understanding.
" ` Y11ef,or HUTnon yea/tBent'stsiame(ElecUonic Signature)
Date
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 not have access to the arbitration
program or guaranty fiord under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.eov/oca information on the Construction Supervisor License can be found at www.mass.eov/dns
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"