25 BERTUCCIO AVE - BPA-15-1130 INSULATION 25� Gy— t 1 3"6 S
w
a The Commonwealth of Massachusetts RECEIVED CITY OF
Board of Building Regulations and StandibtfsPECTIONA L $E LEM
ex<<ll4 = Massachusetts State Building Code,780 CMR VICE
j�. Revised Mar 2011
Building Permit Application To Construct, Repair, RenovaSITF91AP _ 22
One-or Two-Family Dwelling
This Section For Official Use Only - -
nV Building Permit Number: Date Ap lied:
In Building Official(Print Name) Signature Date
U , SECTION 1:SITE INFORMATION
1.1 Prope �dares • 1.2 Assessors Ma &Parcel Numbers
P
L l a Is this an accepted street?yes_ no Map Number Parcel Number
I1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(11)
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❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check ifyesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow r`of Record,;.--
ecord .�
r-yt4 Jav-dai,1 ,�ew� /y►9
Name(Print)Q City,State,ZIP
�� V r-FKC-r D
No. Axt—
and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description ofProposed Work-2-
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 00, — 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 (HVAC) $ List:
5.Mechanical (Fire
Su ression $ Total All Fees:$
L6. Total Project Cost: Sq�� _Check No. 113 S Check Amount: Cash Amount:
} ❑Paid in Full ❑Outstanding Balance Due:
t11ta\Lt—D ItJ 5(�S� IQL7��
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) "f-7 y/7,3
License Number Expiration Date
Name of CSL Holder
Eric W.Palm List CSL Type(see below)_L(
No.and Street 3 Hilton Street Type Description
Salem MA 01970 U Unrestricted(Buildings up to 35,000 cu.R
R Restricted 1&2 Family Dwelling
City/town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
9� �/A �/K SF Solid Fuel Burning Appliances
"[ O I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
Atlantic Weather' ation,LLC
HIC Registration Number Expiration Date
HIC Comp�gy.Alajggf,�),�,RA Name
No.and Streelt ale1I1 Email address
City/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 a building permit
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize E-�-, G 194/I?Yt
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Narke(glectronic 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
contain din this a�catt, a and accurate to the best of my knowledge and understanding. I
• r'^I
Print Owner's or Authorized Agenf s Name(Electronic Signature) d 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 RIC Program can be found at
3!•wo..mass gov/oca Information on the Construction Supervisor License can be found at tv:vw.mass._owtlns
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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'