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10 ALLEN ST - BPA-14-1769 11 REPLACE WINDOWS �!3-I - 1 7(0 C PToficac X035 ` 2 The Commonwealth of MassachusettgNSPECTIONAL SE VICE Y OF Board of Building Regulations and Standards SALEM Massachusetts State Building Code, 730 Clv(8I4 NOV 10 A 9{�4>y0l,tlur 2011 Building Permit Application To Construct, Repair, RenovateOrDemolish a One-or Two-Fmnily Dwelling ------------------ This Section For Official seOn ' \ Building Permit Number: Date Applied: Building Otlicial(Print Name). Signature Date SECTION t:SITE INFORMATION} 1.1 Property Address: D (\f I e n 1.2 Assessors NInp&Parcel Numbers L i a Is this an accepted street?yes no J/ Map Number Parcel Number 1.3 Zoning Information: 1.3 Property Dimensions: Zoning District Proposed Use Lot Area(sq It) Frontage(Il) 1.5 Building Setbacks(B) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Nater Supply:(M.O.I,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: Outside Flood Zone? Municipal ❑ On site disposal system 13Public 13 Private C1 — Check if yesC1 SECTION2. PROPERTYOWNERSHIP'"n/1 d y� 2.1 Ownerlof.q� Vkq n 6be 9r I(n, M !rt ! �U W� me(Print) ((JJ City,State,ZIP -73 1 979 ' 745 ' Lf No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) I Alteration(s) ❑ Addition ❑ Demolition ❑ I Accessory Bldg.❑ Number of Units_ Cher ❑ Specify: Brief Description of Proposed Work': T L G hl e�)� i✓� Dtl I u � c SECTION J: ESTIMATED CONSTRUCTION COSTS I[cnt Estimated Costs: Official Use Only Labor and Materials) 1. Building $ I. Building Permit Fee:$ Indicate how fee is determined: Y ❑Standard CitylTown Application Fee 2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 1,4therFees: S d..Mechanical (FIVP.C) S List: 5. Mechanical (Fire S Total All Fees: S Suppression) _ Cheek No. Check Amount: Cash Amount: 6. Tutal Project Cost: $ r j 5(s-,>' 0 Paid in Full 0 Outstanding Balance Due: 1 SECTION 5: CONSTRUCTION SERVICES 5.1 (�,�/truction Su9pervisor License(CSL) �t (�99 T ,Qlo J�•..I"" Poe, � © b V License Number Expiration Dale Name of CSL Holdert List CSL Type(see below) � 7 (.t)h�.(,e i -S h^ ' Type � - '� - Description No. ;rad Street •7 b U Unrestricted(Buildings to incu. f). V R Restricted 1&22 F tip Dwelling City/Town,Slate,"LIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances V3q1 Insulation Tele hone Email address D Demolition 5.2 Registered 11ome/Improvement Contractor(HIC) �j `I 3 3 'y'A `Y' e"- I HIC Registration Number Expiration Date IIICqnia•utrNam• rillC,Registmnt ne D � 1�i7.S�v� w'n i0•.L'Q (�utY � l No. andS Email address �t r�,to S b Day Mfh y D i - 6 7'9'O L/-3Q Cit /Town,State ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.§ 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 Issuance of the building permit. Signed Affidavit Attached? Yes .......... No........... ❑ SECTION 7a:OWNER AUTHORIZATION.TO HE COMPLETED WHEN ' OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property,hereby authorize l r t PQ K .'V r A.P Jr� t9 act on my behalf,in all matters relative to work authorized by this building permit application. SEE 00V11*41 & / l - IU Print Owner's Natne(Electronic Signature) Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below,l 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. i►1t921L lUlwilNl� . . �.. " mac l �— 10 —I � Print Owacr's or Authorize ger 's N:une(E•lectroni Signature) . Dale NOTES: 1. 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 Florae Improvement Contractor(HIC) Program),will not have access to the arbitration program or guaranty fund under INALG.L.c. 142A.Other important information on the HIC Program can be found at www mass, vs o Information on the Construction Supervisor License can be found at wtrw.mas�•ov:'dps . 2. When substantia(work is planned, provide the information below: Total floor area(sq. ft.) `s :(including garage, finished basementlattics,decks or porch) Gross living area(sq. R.) Habitable room count Number of fireplaces dumber of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open i. "Total Project Square Footage"may be substituted for"fond Project Cost"