14 AMANDA WAY - BPA-14-1741 $ZG�
The Commonwealth of Massachusetts
CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CNIR Revised Aktr 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
Orte-or Two-Family Dwelling
_ This Section For Official my iT
Building Permit Number: Date A plied: rn
o rn
T
Building Otlicial(Print Name). - Signatures Date G
SECTION 1:SITE INFORMATION
1.1 Prope ty Addres2f 1.2 Assessors Map 3r Parcel Numbers N
L __►Ydu tr y —.eri
L la Is this an accepted street?yes_tz no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yams 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesE3
SECTIONI: PROPERTY OWNERSHIPt
2.I'Ownerl of core ��A
r 7
!hme(Print) City,State,ZIP
,��A•Y4KG✓ct Gfistli �� �47Pi/7/R �r.bio s,..�.`s>� `►
Nu. and SLMet Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Buildin Owner-Occupied Repairs(s) ❑ I Alteration(s) ❑ 1 Addition 46—
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work t r
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S ZROVO. Op 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
3. Plumbing S S Other Fees: S
-1. %tech:utical (tIVAC) S List:
5. Mechanical (Fire _ "total All Fees:S
Suppression)
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S ❑Paid in Full ❑Outstanding Balance Due:
-M V( . p _ 1AJ7
��5
SECTION 5: CONSTRUCTION SERVICES
5.1 Cotstruction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder List CSL Type(see below)
:.
Type� - - . , '� - Description
ROT aiid Street
U Unrestricted Duildin s Lip to 35,000 cu. It.)
R Restricted 1&2 Family Dwelling
Cityffown,Sane,ZIP M Masonry
"2 RC Rooting Covering
WS Window and Siding
V SF Solid Fuel Burning Appliances
< 1 Insulation
-Telephone Email address D Demolition
• 5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Dane
f IIC Comp:my None or HIC Registrant Name
No.and Street Email address
City/Town,State ZIP Telephone
SECTION 6:WORKERS'CONIPENSATION 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 Issuance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No........... ❑
SECTION 7a:OWNER AUTHORIZATION:TO BE COMPLETED WHEN
OWNER'S AGENTOR CONTRACTORAPPLIESTOR BUILDING PEPAHT'
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) Dale
SECTION 7b:OWNERI 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 application is true and accurate to the best of my knowledge and understanding. .
Print 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+rut have access to the arbitration
program or guaranty fund under M.G.L.c. 1 J2A. Other important information on the HIC Program can be found at
www.mass. oy. v'oca Information on the Construction Supervisor License can be tbund at www.mas.�•o+:'dys .
2. When substantial work is planned, provide the information below:
'total floor area(sq. ftJ " ,(including garage, finished basement/attics,decks or porch)
Gross living area(sq. 11.) Habitable room court
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/bmhs
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open_
3. "foul Project Square Footage"may be substituted fur"rota) Project Cost"
� o
I j O
W O o
r, (00
HT'f N O) ro ,0
1--1WO N Z)
3
� wM
a - i a)
Q
E 0c) t
W J N r,
11��11 6 O)
I� 0) N
EXIST. 6'-2j"
BATH BATH "
a�
r_ 3'
BEDROOM BEDROOM
O
a
SH LINE INDICATES
W ATTIC OPENINGOVE, PROVIDE 36" Q
GH RAILING ABOVE M Q
DN �� �� DN AND BLOCK BELOW Z m
NEW STAIR FOR SAFETY Q
CUT EXISTING
1 RAILING TO a W
HALL LY I HALL ACCOMMODATESTAIR '~ J
BEDROOM NON BEDROOM N N
BEDROOM BEDROOM
ISSUE DATE:-
JOB NUMBER: .
DRAWN BY: MB
SCALE: AS NOTED
REVISIONS:
EXISTING PART. 2ND FLOOR PLAN PROPOSED PART. 2ND FLOOR PLAN
SCALE: 1/4 = 1'-O" SCALE: 1/4" = 1'-O"
PR ® GRESS A9-29-14