20-1 AMERICA WAY - BPA-11-127 REMODEL KITCHEN The Commonwealth of Massachusetts
CITY
� Board of Building Regulations and Standards
/ Massachusetts State Building Code, 780 CMR, 7'" edition OF SALEM
11 Revised Jannraly
Building Permit Application To Construct, Repair,Renovate Or Demolish a 1, 2008
One- or Two-Family Dwellin
This tion For Official Vse Only
Building Permit Number: D e lied:
Signature:
Building Commissi er/Inspector o Buil ' ' Date
SEC 1 1: SITE INFORMATION
1.1 Property Ad ress• 1.2 Assessors Map &Parcel Numbers
Q _I
LIa Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
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:
Public li� Private❑ Zone: Outside Flood Zonc? Municipa On site disposal system ❑
Check if ye
SECTION 2: PROPERTY OWNERSHIP'
Owner'of Record: —ro�,_�'`u� t l(C Q,- ev U ni r, b-
11, YCG WGV
Name(Print) I Address for Service:
334 - �r3 3 - o3o(e
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building 94- Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) IV Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units _ Other ❑ Specify:
Brief Description of Proposed Work':
f K 5 tl r l�dN n.� rte Ccl7 r f� Cb�`vt ✓
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (H List:
$ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Super (CSL) CS
TUVI
� lO
�l1D�:�sI C � License Number Expiration ate
NameNameo der 91
�� �,�, �� List CSL Type(see below)
Addre Type Description
Addrefl
U Unrestricted(up to 35,000 Cu.Ft.)
Restricted 1&2 Family Dwelling
Sign �e' _1 2 5— M Mason Only
4
RC Residential Roofing Covering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
2 Registere8 Home�mprovfinent Contractor(HIC) ®� �,p
f19tlyh c Uc yl.. 7
C Company Name or HIC egi ant Nampa. - Registration Number
Gt1G1 1 J
d ss a�.y
�(t-uZ-^ `.,� t� Expiration Date
ure 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 Issuance of the building permit.
Signed Affidavit Attached? Yes ..........90-0 No ........... ❑
SECTION 7n: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, '�rt ctel ge-r I n as Owner of the subject property hereby
authorizes 11 � � _ to act on my behalf,in all matters
relative to work on d by this uilding permit application.
L,,o
Signature of Owner Dale
SECTION 7b::OWNER' OR AUTHORIZED AGENT DECLARATION
1, as Owner or erized hereby declare
that the statemefits and informa on on the foregoing application are true and accurate,to the best of my knowledge and
behalf,
t O fr
Print e
SignLq !U
a Date
rt
(Si med under the pains and penalties of perjury)
NOTES:
l. 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 not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I10.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(Sq.Ft.) Habitable 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 be substituted for"Total Project Cost"