25 BOARDMAN ST - BPA-11-11 ROOF 1*� fhe Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
u OF SALEM
!ty j Massachusetts State Building Cale, 780 CMR, 7 edition RrsisrdJwrriun•
91ww� Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. ?lllAY
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit tuber: 9 Date Applied::
Signature: � /f /fib
Building CommissioKerl Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Prooppe`rt Addddrest: 1.2 Assessors Map& Parcel Numbers
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(sit R) Frontage(11)
1.5 Building Setbacks(R)
From 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? Municipal❑ On site disposal system ❑
Public❑ Private O — Check if yes p D� y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Recorl:
Name(Print) Address for Service:
Signatum Telephone
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 of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard Cityrrown Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List: L_
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: I S 6. Or)r\,) 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) v30
\A',Nt\I\ \r` I.icense Number Espitation )ate
Name ul'C'SL•I lulder I.ist CSL Type(see below)
4u
Description,000
Address
U llnresuicteJ u to)5000 Cu.Ft.
R Restricted 1&2 FamilyDwelling
Signature M Masonry Onl
RC I Residential Roofing Covering '..
felephtme I WS I Residential Window and Siding
SF Residential Solid Fuel Burning Aopliance Installation
D Residential Demolition
5.2 R�Vtered Home Improvement Contractor(HIC)
5 l.,A", \
Registration
I IIC Company Name or HIC Registr�nl Name N
Ilk
Address S. /
o�-�� �=�'� "� Espiration'7umber
�te
Signature 'relephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152. 1 2SC(6))
Workers Compensation Insurance atTtdavit 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 ..........C3 No...........O
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 to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7z1b:OWNEW OR AUTHORIZED AGENT DECLARATION
1, .��: 1" y yl . ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. v ` \\)
Print Name
Signature of Owner or Authorized Allfirt Date
(Signed 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 raj have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS,respectively.
?. 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
1. "Total Project Square Footage"maybe substituted for"Total Project Cost"