15-17 BOSTON ST - BPA-10-217 ROOF &N The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
/ OF SALEM
Massachusetts State Building Code, 780 CMR, 7a'edition
i
Revised January
Building Perntit Application To Construct,Repair,Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
This Section For Official Use Only .
Building Permit Number Date Applied
J
Signature:
Building Commissioner/Insp6dfor of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
/S• /'7 /9trJS�yn/S
1.1 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 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.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 OWNERSIIIP1
2.1 Owner'of Record:
/f-/-719dSd.,1-V'/-
Name rint) Address for Service:
X 1-y-- 9 7D` �_i i-3a1
Signature Telephone -
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Own r-Occupied ❑ Repairs(',) ❑ 1 Alteration(,) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify: g, =
Brief Description of Proposed Work': //
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only `.
(Labor and Materials)
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Pro)ect Cost',(Item 6)x multiplier - x
3.Plumbing $ 2. OdterFees $
4.Mechanical (HVAC) $ List
5.Mechanical (Fire $
Su cession Total AI1Fees. $
Check No Check Amount Cash Amount.
6. Total Project Cost: $ 7 ❑Paid in Full ❑Outstanding Balance Due:
I
SECTIONS:=CONSTRUCTIONSERVICES �r
5.1 Licensed Construction Supervisor(CSL)
�/rr rlie p.rIed X11-1e.6 Licenseense Num�r Expiration Date
Name of CSL-Holder
� List CSL Type(see below) y
Address %T4 DeScri lion
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
7,P 2" f7// RC Residential Routing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
l ea u 'L r •e ez /Yd"f ZZ
HIC Company Name or HIC Registrant Name Registration Number
Address
"' - 54h,/��L-�-� 78/ 7J''9 9 7C/ F.xpimtion Date
Signature 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 lssuance of the building permit.
Signed Affidavit Attached'? Yes.......... Di No...........❑
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT.OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, �%%/f V as Owner of the subject property hercbv
authorize / ,� LV/L •1.•�. ,/. %/�.,(ie �— to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner X Date
SECTION 7bt OWNEW OR AUTHORIZED AGENT DECLARATION
1 c 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.
Z A ./✓'/./<.L/ L
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 11O.R6 and 110.R5,respectively.
2. When substantial work is planned;provide the information below:
Total floors area(Sq,Ft.) (including garage,finished basementlattics,decks or porch)
Gross living area(Sq. FtJ Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Nurnber 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"