80 BAY VIEW AVE - BPA-12-02 REMOVE/REPLACE PORCH & ROOF Fhe Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
SALEM
Massachusetts State Building Code, 780 CMR Reviser/ Var '011
Building Permit Application To Construct, Repair, Renovate Or Denolish a
Otte-or Two-Futni(v Duelling
This Section For Official Use Ot
Building Permit Number: I Date plied:
J - C
Building Official(Print Nmne) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
Sre 3.1y Vlfry �rE
I.I a 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 It) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provide)
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 yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 O�{r er of Record-
K06t-R'i- eHribWleK SA[-EM AK 0t97o
Mane(Print) City.State,ZIP
go /ivy tlmw Ar 77k 6&1 Y72s' r"cha,'�2.6L2 3MA4
Nu.and Street "relephone Email Add ss
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied 13 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': a n l x ar
n&,Myrfs We Sao rvooc
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building Y o 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
'-. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 1. OLIt�Feds�$ ��
4. ,Mechanical (IIVAC) S List: �1,, _ /
0
S. ,�I'chnt acal IFire $
S u s lesion l Total All Fees:$
Check No. _Check Amount__—Cash Amount:- _-
G. Total Project Cost: 5 ❑ Paid in Full ❑Outstanding Balance Due:
'�'►'�,Q � r�p�xPOGUh�
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number -- Aspiration Date
Nanic of C'SI. I]older - — - -
List CSL Type(sae helow)
No. and Street Type Description
tl IhircslricteJ Buildings up in 35,000 cu. it.)
R Restricted 1&2 Family Dwellin
Cilyi l'osw,State.ZIP M Mason
ry
RC Rooting Covcrin
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
'fcic hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Registration Number lispiruion Date
I IIC'Company Name or I IIC' Itegislrunt Name
No.and Street
Email address
City/Town,State, ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this of davit 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 AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER/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.
Prim Oe ner's or \uthorizeJ.lgcnt's Name(lilecnunic Signature) atn
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 not have access to the arbitration
program or guaranty fund under NI.G.L.c. MIA.Other important information on the HIC Program can be found at
yogis.n]_I ,.g,ip oc:) Information on the Construction Supervisor License can be found at n,us.yn 'dtr
2. When substantial work is planned, provide the information below:
Total Boor area(sq. ft.) (including garage, finished basenient'attics,decks or porch)
Gross living area(sq. It.) _ __ Habitable room count
Number of fireplaces----_---- Number of bedrooms Number of of bathroonis Number of halfb;uhs
1'. pe of locating system Number of decks• porches.----
Enclosed
i "Fotol Project Square Footage"may be Substituted for• rotal Project Cost"