16 BECKET ST - BPA-2010-614 I The Commonwealth of Massachusetts
,I;►� :� Board of Building Regulations and Standards CITY
/ t l Massachusetts State Building Code, 780 CMR, 7ih edition OF SALEM Revised January
Building Permit Application To Construct,Repair, Renovate Or Demolish a /. 2008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit u er Date Applied: 2� l
Signature:
i Building Commi io I spectorof Buildings Date
SECTION I:SITE INFORMATION
Y 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
L 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 11) Frontage(11)
I.5 Building Setbacks(D)
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:
Zone: _ Outside Flood Zone?
Public❑ Private ElCheck if es❑ I Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
1.1` wnert of R rd: , P c�-
x �� 2
Name PH t) Address for Service:
Signa �� "telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKr(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Altejaton(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': e
C6 &$OWt �Q 'k i lV rr �Rlf4
X e .%AAOt._ AE, A
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S - 1. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical S OQ� /tri ❑Standard Citylrown Application Fee
�!J ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 60 t 6V 2. Other Fees: S
4. Mechanical (fIVAC) $ List:
5. Mechanical (Fire Suppression)
S Total All Fees:S
Check No._Check Amount: Cash Amount:_
�( 6.Total Project Cost: S VtW 13 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number I:!(pintllUn Date
Name of C'SL•I folder List CSL Type(see below)
f I) n tion
Address U Unrestricted(up to 35,000 Cu.Ft.
R Restricted IR2 Family Dwelling
Signature M Masonry Only
RC Residential Rooting C'overin
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,a 152.9 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..........O 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.
Si lure of Owner Date
SECTION 7b:OWNER/t OR AUTHORIZED AGENT DECLARATION
f &"V (VIAk e%l-J?( ,as Owner or Authorized Agent hereby declare
x that the statements and itiformation on the foregoing application are true and accurate,to the best of my knowledge and
behalf. t
Q/2C
Print Name
C.z.
Signature of( wner or Authorized Agent Date
(Sianed under the pains and penalties of 'u
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 VJ 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 110.116 and I IO.RS,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. .To
Project Square Footage"may be substituted for"Total Project Cost"