35 ARBELLA ST - BPA-14-400 REMODEL 2ND FL BATH lac q< q(ogz
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
\�J/ Massachusetts State Building Code, 780 CMR Revised Mar 2011
' Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
r T41s Section For'Official Use'Only ' t..
Building Permit Number `,' g` Dat plied
Buildin OffciaL(PrmtName)�r
SECTION-1 SITE PNFORMATI0
1.1 Property dd ess: 1.2 Assessors Map& Parcel Numbers
1.1 a Is this n accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use or 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.TO,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ P P
Check if yes❑
SE;CTION 2:`PROPEI2TX OWNERSHIP'
2.1 Owner'of Record:
le. (bt �o.is e ��rleH SA,leon AAA 001-0
Name(Print) City,State,ZIP I /
J3S A rIV tIA S4rtd- 478•-7`V1•,94*9 1• Gvr ComCRSf: /lE�
No. and Street Telephone — � Et it Address
SECTION 3.DESCRIPTION Oh PROPOSED'WORK2(check all that apply}
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ I Repairs(s)X, Atteration(s) ❑ Add
ition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Desc,iption of Proposed Work':
a -44 lop Je) A�Jr/ N VS 621Y jr777777777777777.
SECTION 4 ESTIMATED CONSTRUCTION COSTS r
Estimated Costs. „ e `
Item Labor and Materials :. z. *, Offietal]U Only
1. Building $ 00 Building Permit Fde $ Indicate how fee is de[ern med.
2. Electrical $ '41 QO Standard Ctty/Town Apphcahon Fee x '
❑TotalPiolect Cost',(Itein 6)xmulhplicr' x
u -
3.Plumbing $ o , 2. OtherFees $
4. Mechanical (HVAC) $ List
u
5. Mechanical (Fire $ Total All Fees $
Su ression
1 Check No: Check Amount` Cash Amount
6. Total Project Cost: $ 2 5700ei❑Paid inFull . ❑ Outstanding 1�alance Due:
7
r
SECTION 5: CONSTRUCTION SERVICES
5..11 Construction Supervisor License(CSL) � �y
9 Q�f r A Cat a.rA CY License Number Expiration Date
Name
77 of CSSSL Holder r
List CSL Type(see below) __
No. and Street - Type. DescripitoLi ,
141, �.f/I� �� O� - U Unrestricted Buildin s u to 35,000 cu. ft.)
000 111///111 �'✓� R Restricted 1&2 FamilyDwelling
City/Town, Stale,ZIP MMU
ry
Roverin
Wnd Sidin
�{ �,/�93
^� SF Burning Appliances
2 O` Fo� I
Telephone Email address Dn
5 egistered,H/o/'opie Improvement C ntractor(HIC) � 7 � /
�0 �'�"'���� �y8) !tl HIC Registration Number Expiration Date
HIC Company Nam or HIC Registrant Name
/ p�
We.and Sir t Email address
Ci /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 Issuance of the building permit.
Signed Affidavit Attached? Yes ..........3y—,— No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN -
OWNER'S AGENT OR CONTRACTOR APPLIES FORBUILDIING PERMIT
I, as Owner of the subject property,hereby authorize Pox r M/�j/�/
to act on my behalf, in all matters relative to work authorized by this building per it application.
Je..owr2 f)'l, Va✓t.d � G, /. ml /N( utr 12 s t3
Print Owner's Nam (Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATIO
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.
�lp
� r Alta
� 02 ..
Pnnt3 or Authorized Agent's N (Electronic Signature) / / Date
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 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 can be found at
www.mass._>ov/oca Information on the Construction Supervisor License can be found at www.mass.eov+dns
2. When substantial work is planned,provide the information below:
Total floor 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"
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