3 ALLEN ST - BPA-12-505 REPLACE FRONT STEPS The Commonwealth of Massachusetts CITY
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Board ofBuildmg Regulutions and StandardsOF SALEMC'Massachusetts State Building Code, 780 MR, 7ib edition Revised JurnawY
Building Permit Application'fo Construct, Repair, Renoatev Demolish a I. _oox
One-or Ttvo-Family Dwelling
This eca in Official Us nl
Building Permit Number• ate ied:
Signature: I./ ..o
l/Jhl o
Building Commissioner/Inspector o II i Date
SECT O 1:SITE INFORNIATION
1.1 ProperiAd 77 /^ 5 1.2 Assessors Map& Parcel Numbers
L�T M Number Parcel Number
I.I a Is this an accepted street?yes no a_ P
1.3 Zoning Information: ` 1.4 Property Dimensions:
Zoning District ProPe.ed DSe tl ' Lot Area(sq 11) Frontage(ft)
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? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow er' ecord ?
Name( t / t Ad/d�rers—s�for Service: �7
v / IG�/
/�— Signature 'telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner•Occupied ❑ Repairs(s) Alterations) ❑ Addition ❑
Demolition 0 Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Des ption of Proposed,Wor =
-Pij7�.� XIS�/N � OY Sf S �A.JS CabY) fP
r e —
SECTION 4. ESTI A ED CONSTRUCTION COSTS
Estimated Costs: Offlclal Use Only
rials
Item I Labor and Mate
I. Building S �Sjj, I. Building Permit Fee: S Indicate how 1'ee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)s multiplier s
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S Total All Fees:S
Suppression)
Check No. _Check Amount: Cash Amount:_
6.Total Project Cost: S a tf�V OV_ ❑Paid in Full ❑Outstanding Balance Due:
9-
r 9,
relcphone
ECTION 5: CONSTRUCTION SERVICES
Licensed Construction Supervisor(CSL) J.-7 Y r
{'�l I C,&r- 1 tY License NumberI lul cr Lis1CSL)y pe lsee below) ,. .,t Descri lion
II ' Unrestricted u to 35,000 Cu. Ft.)
DR Restricted Idt2 Famil Dwelliny— a.3o a. h, Mason Only
RC Residential Rrwlin Covering
Telephone WS Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
U Residential Demolition
R Istefgd �{�ne InWro ment C nIractor HIC
jPTP y✓//��sfav10/1V �uv, [l'� vt�co�/ /030 &S
IC Comps Name or IIIC Re istrant Name Registration Number
14
Expiration Date
Signature 'telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 ..........X_ No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
�, I• �`_ y-h.' l lf!Q P/,' F,s Owner of the subject property hereby
authorize / / to act on my behalf, in all matters
relative to work authorized by this b ilding permit application.
Si atu ol'Owner Zl'
Date
n ,tSECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
I, U'e Tf'r l',tVI 1 Cq a A n srewneror 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.PP, �A A
Print ame I"'
/
Sign lure ol'Owner ur Authorized Agent Date
(Signed under the pains and penalties ofperjury)
NOTES:
1. An Owner who obtains a building permit to do hislher own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(IIIC)Program),will W have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the MC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total Iloors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Ilabitable 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 he substituted for"Total Project Cost"
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