15 ALBION ST - BPA-11-362 ROOF The Commonwealth of Massachusetts
i I Board ul'Building Regulations and Standard - CITY
/ Massachusetts State Building Code. 780 CMR, cdilion OF SALEM
vat
Rnisrr/Jmnavc
Building Permit Application To Construct, Repair, noe Or Demolish a /. 1fNAY
One-o e -Family Dwel ng
Yfiis Sec ion For OIT al Use Only
Building Permit No q4te Applied:
Signature: � /O/01.. I//U
Building Commission In a Bui Dan
S 1 N 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Number
S AcQrorJ STiLQ
1.1 a Is this an acce Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Propowd Use Log Area(sq 11) Frontage(11)
1.3 Building Setbacks(ft)
From Yard Side Yards Rear Ywd
FSECTION
d Provided Required Provided Required Provided
Supply:(M.C.L c.40,§54) 1.7 Flood Zone Information: I.8 Sewage Disposal System:
Private❑ Zone: Outside Flood Zon7 Municipal❑ On site disposal system ❑Check if es❑
SECTION2: PRO RTYOWNERSHIP'
'of Record:
l A-�Lr�)o C� / � prC.t'�100�1 S`i SJ�Leti..t tun 4kAddress for Service:
/ -- 948t-fr3 S- q
,.V Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ umber of Units_ Other ❑ Specify:
Brief Description of Proposed Work': ND i7 rap o o F $/+1 6 LU 5 TV
`-6k rs S PG-n -,-J e- P + P o lo-
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Offlelal Use Only
Labor and Materials
I. Building is 1. Building Permit Fee: S Indicate how tee is determined:
❑Standard City/Town Application Fee
?. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing s 2. Other Fen: S
4. Mechanical (fIVAC) $ List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
aW Check No. Check Amount: Cash Amount:
6. Total Project Cost: O Paid in Full O Outstanding Balance Due:
%SDo
SECTION !: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number F%pitaliun Date
Name of l'SI.• I lulder I.iu CSL Type Isee below)
f I)<scri ion
:Address U I lnresirictcd t 14 n00 Cu. Ft. ,-
R Restricted IR2 F—J Uwellin
tiianamre M M (MI
RC Residential Roulin Coverin
I'eleplrate WS Residential Window and SiJin
SF Residential Solid Fuel Bumin A Iian.Y Installation
D Rnidential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or HIC Registrant Name Registration Number
Address Expiration Date
Signature 'relephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.f 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..........o 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.
Simusurcof0wrier Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1 �1 ,as Owner or Authorized Agent hereby declare
that the tements and information on the foregoing application are true and accurate,to the best of my knowledge and
alf. l ` - ;
Prim Name h'2-�`-'
Signature ofOwner or uthorized Agent Date T
Si under the in and naltin of 'u
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 Og have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I IO.R6 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basemenUattics,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
J. "Total Project Square Footage"may be substituted for-Total Project Cost"