14 BERTUCCIO AVE - BPA-13-7-3 HC RAMP 3z, �v
The Commonwealth of Massachusetts
Board of Buildino Regulations and Standards CITY OF
�1 SALEM
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� Massachusetts State Building Code, 780 CNIR Revised Mar 2011
Y Ill Building Permit Application To Construct, Repair, Renovate Or D sh a
One-or Two-Family Dwelling
This Section;ForOfficial Use Ogl
Building Permit Numberr. Date plied?< ;r
;, � Z
Building Official(Print Name) `S' nature Dater
SECTION 1: SITE FORT TfQN�/
1.1 Property Address: .2 Assessor lV[a Parcel Numbers
g`'f E/17-4,eea i?Ile —
l.t a Is this an accepted street?yes_ no Ma umber 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.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private ❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2:` PROPERTY OWNERSHIP''
2.1 Ownert of Record:
pl Name(Print) City,State,ZIP
N/I/L 5-41-W SoLEryt ArS
No. and Streetf 7 Telephone /Gry Email Address
SECTION 3: DESCRIPTION OF.PROPOSED WORK='(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': _ e
l pO SECTION 4: ESTINUTED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only,,
Labor and Materials
1. Building S I Building Permit Fee: $ Indicate how fee is determined:
�. Electrical S Cl.Standard.City/Town Application Fee
❑Total Project Cost',(Item.6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire $
Suppression) rota!All Fees: .S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ �. �� ❑ Paid in Full ❑ Outstanding Valance Duc:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL holder
List CSL Type(sae below)
Type Description
No. and-Street
U Unrestricted BriiWin s up to 35,000 cu. ft.)
R Restricted 1&2 Family Dwellin
Cityrrown, State, ZIP M f`lasonr
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Hone Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No. and Street Email address
City/Town, State, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L,e. 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 AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property, hereby authorize
to act on my behalf, in all(natters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7h: 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.
a/ _T05c nh S41W �-as-ao,3
Print Owner's or Authorized Agent's Name(Elecn'onic 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 not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the IIIC Program can be found at
ww-w.mass.,ovroca Information on the Construction Supervisor License can be found at www.mass.eovAlp_s
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 or Cu eplaccs____ Number of bedrooms
Number of bathrooms Number of half/baths
rype of heating system __- Number of decks/ porches -----
hYpe orcooling system__.__-- Enclosed --
}, 'Fotal Ili ojcct tiqu,ue Po0m,e" may be sub_titutcd roi--I'otnl Project Cost" - ---- - --
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