9 1-2 ALBION ST - BUILDING INSPECTION (2) The Coin tnonwcalth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 730 CINIR Revised ib/nr 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-o ivo-Family velling
his S ctionFo ' fficial Use Only
Building Permit Number: Date Ap ed.;.
Building Official(Print Name) Signatur Dnte
C N I:SITE INFORNIATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
f_L,�?
1.l a Is this an accepted street?yes k'f 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 yes❑ Municipal ff�On site disposal system CI
SECTION 2:, PAOPERTY OWNERSIIIPL
2.1 Ownert of Record:
0o22'eh-ie k,zbud y side SIT o/g/,s-
Naame(Prinn7t) City,State,ZIP
No.and Street Telephone Enail Address
SECTION 3: DESCRIPTION OF PROPOSED WORIO'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs a) Cl I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': /R. J, A- ✓11 C
SECTION 4: ESTINLATED CONSTRUCTION COSTS
Estimated Costs:
Rem Official Use Only. ,
Labor and i✓taterials
I. Building 3 3 Sc, 1. Building Permit Fee.9 Indicate how fee is determined:
❑Standard.CityCrownApplication Fee
2. Electrical 5
❑'Corot Project Cost](Item 6)x multiplier x
1. echo is S 2. Other Fees: $t. Mechanical (fIV.\O) i List: t �
5. %lechanical (Fire
} .S
Snp ress ion) _ -
Check No. __Check Amount __Cash Autuunt---
1'utal Project Cost: Coral:Ul Fees:
p Paid in Fall Cl Outstanding Balance Rio-
r
SECTION 5: Co:NS'rRUCTION SERVICES
r5.1onstructionSupervisorLicense(CSL,) 2 Z 6 C. License Number Gepiration D to
of CSL I folderList CSL Type(see below)
� 4fL SL ✓F.^� m(
Type Description
No. and Street
U Unrestricted(Buildings s up to 35,000 cu. ft.
C 6 /NS G t s'! s- R Restricted 1&2 Faintly Dwelling
City/Town,State, ZIP M i\dasonr
RC Rootin covering
WS WindowandSidin,
SF Solid Fuel Burning Appliances
�75 36 y 6�i�� 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(FIIC) 17/167 2- !3 !4
r-A,4 T j T r .l A•%0 MC Registration Number Expiration Date
-
I IIC Coin, ny Name or FIIC Registrant Name
iF4 rc SL No.Md Street Email address
$e P ! /h i7 9�b 3aY 6 4C7
City/To wn,State, ZIP Telephone
SECTION 6: WORKERS' COMPENSAT[ON 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 .......... Er'� No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
EOwner's
ubject property,hereby authorize �`t�� kAs Zv 6A
, in all matters relative to work authorized by this building permit application.
�Y� 5- 17- /3
Electronic Signature) 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
contained in this application is true and accurate to the best of my knowledge and understanding.
int Owner's or A itcd.\;cnt's Name(Electronic 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
(nut registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty fund under NI.G.L. C. 142A. Other important information on the HIC Program can be found at
www.m:us. oca Information on the Construction Supervisor License can be found at wwo.mass, u�'dL
2. When substantial work is planned,provide the information below:
Total tloor area(ski. It.) _(including garage, tinislied bascmcnt/attiu, decks or porch)
tiros; living nica(sy. tl — habitable room count
Number of lirapl.tees,_--_._----- `lumber of bedrooms __--
Number of bathrooms Number of halt;baths --_—__-- —
-
I'vpeoFheatingsy,lem .. _-- f'''umberofdecks/ porches
pe of CoOling sy.tcnt
� i. `I',it.il I'rnj�ct 1 �u,trc F „�! i,e m•ty hc ,nb;tihrt I t r"I', i.�l 19u'�cd l',rvt"