10 ALLEN ST - BPA-14-1945 REPLACE 11 WINDOWS Sc (C ¢2.
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
1
WIO/ CMRMassachusetts State Building Code, 780 Revised,4lur 1011
l
Building Permit Application To Construct, Repair, Renovate Or Demolish 3
One-or Tivo-Family Dtvellhrg
This Section For Official Use Only
Q` Building Permit Number: Date.Applied.
1 Building Otiicial(Print Name). Signature Dote
SECTION 1:SITE'INFORt1MATION'
1.1 Property Address: � I\ � I�� n S �f 1.2 Assessors binp 3o Parcel Numbers
1. a Is this an accepted street?yeses no t blap Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Arca(sq 11) Frontage(It)
1.5 Building Setbacks(ft) -
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
1.6 Nater Supply:(M.G.L c.40,934) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system 13Public[3 Private 13 Zone:
if yes13
SECTION 2: PROPERTYOWNERSHIP� /
2.t OwnertofRecor�h� ��� Ue �SA �l/� fg7C
t7;1me(Pri it)
ny City,Stat ZIP_ ,'
' " " I I� S.� _ �} -3 Email Address
No. and Strect Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s)ag,I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed\V
fy{
tel/
SECTION 4: ESTIijNIA D CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ `j S 7 — 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(item 6)x multiplier x
3. Plumbing S 'Pother Fees: S
d.&Icchanical (11VAC) S - List:
5. \fechanical (Fire S Total All Fees:S
Su ressiun)
y Check No. Check Amount: Cash Amount: i
G. Total Project Cost: S ❑ Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction S[li�)7 ervisor Lic__ense(CSL)
2 t� `Y j0 CZ r
D t License Number Expiration Dale
Name of CSL I Holder List
List CSL'rype(see below)
j 7 - W f' . •Q,r ..
Type -.. - - Description
No id Street
\ � ,A O �p U Unrestricted(Buildings u i to 35,000 cu. ft.)
J V+� R Restricted 1&2 Family Dwelling
City/Town,Slate,ZIP M Masonry
RC Roo ling Covering
WS Window and Siding
'r nn n SF Solid Fuel Burning Appliances
Insulation
Tele hone Email address D Demolition
5.2 Registered Home (�n/rp�rovement Contractor(HIC) g
qy u g f U�rgo e `fir L HIC Registration Number Expiration Date
if C,
d.7NlYc C�ltlrrntt i)2*
No. �ud,�lFeCL�r,6 � wl `W `�?(J Email address
Cit /Town,State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION 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 Is4uance of the building permit.
Signed Affidavit Attached? Yes ....... .. No........... 0
SECTION 7up OWNER AUTHORIZATION.TO HE COMPLETED.WHEN.' -
OWNER'S AGENT OR CONTRACTOkAPPLIES/F�OR 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. (/
SL [` C d� ryGL� / 2 — Z � � " /
Print Owner's Nane(Electronic Signature) Date
SECTION 7b: OWNEW 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 a plication is true an accurate to the best of lfly knowledge and understanding.
Print Owner's u Autl)orizcd r\•• s Name(Electronic Signatitre) Date
NOTES:
I. An Owner who obtains a building permit to do his/herown work,or anowner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program),will not 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
www.mass. •o,v'oas3 Information on the Construction Supervisor License can be found at AAA, ass.eov'dos
2. When substantial work is planned,provide the information below•.
'rota) floor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces dumber of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
'rypeofcoolingsysten Enclosed Open
1. "Total Project Square Footage•'may be substituted for"rutal Project Cost"