3 ALLEN ST - BPA-16-1182 REPLACE SOME CLAPBOARDS & TRIM 2�-
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The Commonwealth of Massachus t5PE0T-}}j � CITY OF
Board of Building Regulations and Stliidards SALEM
Q � Massachusetts State Building Code, 780 Ah'%CT 13 A Of 2%vireJ Jlur 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
�p Building Permit Numben Date,Applieds la (3 4b
F `?
I Building Official(Print Name) .Signature Date
SECTION I:SITE INFORhIAT10N`
( 1.1 Property Address: 1.2 Assessors blap&Parcel Numbers
_
1.la Is this an accepted street9 yes no Map Number Parcel NumM r
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage(It)
1.5 Building Setbacks(D)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.d0,§5q) 1.7 Flood Zone Information: 1.8,Sewnge Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑ P P y
SECTION2: PROPERTY OWNERSHIP,
2A Owner'of Record:
. KAritk(ZyN `r�tZ SA1-C�
time(Print) City,State,ZIP
?a ALCA7,2 S►, QNt 2 -b551
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building&I Owner-occupied <Repairs(s) bfJ Altemtion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Pr,opposed Work':
iZCFLAoGE CWBOA.f2D5 wHCaZ N lO
E h£Z TP—tHn wifb2E wt&06IN
SECTION J:ESTIMATED CONSTRUCTION COSTS
Ile t Estimated Costs: Official Use Only
Labor and Materials)
1. Building S 3600-00 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
}, Plumbing S 2. Other Fees: S ^b�
4.�icchmical (HVAC) S List: 6^ /
5. \Itchanical (Fire S total All Fees:S
Su ression)
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S '600,00 ❑Paid in Full 0 Outstanding Balance Due:
SECTIONr.5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiation Date
Nanic of CSL Holder List CSL'rype(see below)
Type Description .
No.and Street
U Unnsuicted Ouildin a to 35,W0 cu. R.
R Restricted I&2 Family Dwellin
city/Town,State,ZIP M Masonry
RC Ranting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email iuidress D Demolition
5.2 Registered home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IIIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G,[ c. t$2.§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 Winince of the building permit.
Signed Affidavit Attached? Yes ..........❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION:TO BE COMPLETED WHEN.
OWNER'S AGENT OR CONTRACPORAPPLIES FOR BUILDING.PERMIT
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'ORAUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
co fined in this application is true and accurate to the best of my knowledge and understanding.
XPrint owner's or Authorized Agent'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
(not registered in the Home Improvement Contractor(HIC) Program),will nut have access to the arbitration
program or guaranty fund under I.G.L.c. 142A.Other important information on the HIC Program can be found at
wow mass coy�'oca Information on the Construction Supervisor License can be found at www.niass.aos:'dns
2. When substantial work is planned,provide the information below:
"total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch)
Gross living area(sq. it.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/batlis
'type of heating system Number of decks/porches
rype orcooling system Enclosed Open
3. "rotal Project Square Footage"miry be substiuded for"f utal Project Cost"
CITY OF SALEM, MASSACHUSE TTS
BUILDING DEPARTMENT
120 WASFBNGTON STRMET,3"D FLOOR
TEL.(978)745-9595
KIMBERLEYDRISCOLL FAX(978)740-9846
MAYOR 7}iOMAS ST.PIERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING CDAWSSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
Job Location 3 k-L t J
Home Owner Address_ ( S 44,ttF-1
Present Mailing Address_ Ni-00 C,j, S�g-1,A
The current exemption of"Homeowners"was extended to"include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or
is intended to be, a one=or two-family dwelling, attached or detached structures accessory to such use
and/or farm structures. A person who constructs more than one home in a two year period shall not be
considered a homeowner. Such "homeowner"shall submit to the Building Official, on a form acceptable
to the Building Official,that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner"assumes responsibility for compliance with the State Building Code and
other applicable by-laws and regulations.
The undersigned"homeowner"certifies that he/she understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE =-
APPROVAL OF BUILDING INSPECTOR