65 BOSTON ST - BPA-14-134 ENLARGE LAUNDRY The Commonwealth of Massachusetts
Board of Building Regulations and Standards SALALEM
OF
S Building Code, 730 CNIR Massachusetts State 7t Ravised hfar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Scctiort For Official Use Only
Building Permit Number_ Date Ap Iteda,
Building Official(Print Name),: I Signs ure Date
SECTION 1:SITE'INFOW LATION
L1nrosectg.)ddrpse: 1.2 Assessors tNlap& Parcel Numbers
1.1a 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 apply:(M.G.L c.40,§54) 1.7 Flood Zone Information: GS Sewnge D' osal System:
Public Private❑" Zone: Outside Flood Zone? Municipal On ssite disposal system ❑
Check if yesO
" SECTIONZe; PROPEAT1fOWNERSHIP!
t
z owr �-ef o,A� r� �_ Ate. 1 MA
Name(Print) - City,State,ZIP
No.and Street Telephone �" -Email Address
SECTION 3: DESCRIPTION OFPROPOSEDWOR1e'(cbeckalithatap ly) .
New Construction ❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ 1 Alterat' n(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
B 'ef escrip 'on f Proposed Work':
tca AI
SECTION 4: ESTI1NLkTED CONSTRUCTION COSTS-
Estimated Costs:
Item Official Use Only.,
Labor and Materials
1. Building ; G o6 1. Building Permit Fee:S 't rndicate flow fee is determined:
�. F.Iectrica! $ oo ❑Standard.City/Cown,Application Fee''
�` ❑'fatal Pioject Costs(Item.6)x multiplier
3. Plumbing i , 00 2. OtherPees:'S
i. Mechanical (IIVAQ S List:
i. Mechanical (Fire S
Sup ression) _ Total :\II Fces:$
3 Q, Check No. Chcck Amount: __Cash :\mount:
i, -1'ntol I'i'njcct ('u;t 5 �Wr f ❑ Paid in l'nIl ❑Outaton<hng Ilmlance I?no:__--- ---
,
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Soper`visor License(CSL) e�L_b Lq�21P «
`� License Number Espi lion D;to
Name of CSL I[older List CSL Type(see below)
ad e�� rype Description
No. and Street
1 rq U Unrestricted-(Buildings mi u ln cu. lt.
` C/4 R Restricted LYc2 Family Dwelling
Citylrown,State, Z P bl ,lasonr
RC Ruutin Cov'
1VS Window and Sidin"
SF Solid Fuel taunting Appliances
I Insulation
Tele hune Email address D Demolition
5.2 Registkred Home Iniprovenjent Contractor(HIC) I—) I I I
EIIC Registration Number !E. irat n Date111 I Nam or f IIC Re ' m t N'and t oat Email addre
City/Town,St e, 'ZIP Tale hone
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 of the building permit.
Signed Affidavit Attached? Yes .......... O No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO DE COMPLETED WHEN
O WNERIS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Ow f the subject property,hereby authorize
to act o I beha ' a1 ter alive to work authorized by thisbuilding permit appl• ation.
Print wner's Name onic S gnature) Dote
SECTION 7h: OWNEW OR AUTHORIZED AGENT DECLARATION
.By enter' my n.me below, I ereby attest under the pains and penalties of perjury that all of the information
contai din this pplicatio I true and accurate to the best of my knowledge and understanding.
Print O s or Aut as :\gent's Nano El•• 'c Signature). Date
NOTES:
I. An Owner who obtains a uilding permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Haute Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty find under M.G.L. c. 142A. Other important information on the HIC Program can be found at
Ivh •• Information on the Construction Supervisor License can be found at w\v\v.nuus.,,kwdp_,•,
2. When substantial work is planned,provide the information below:
rord flour area(sy. ft.) —(including garage, finished basemenVattics,decks or porch)
tiros; living area(sq. ft.) flabimble room count _
Number of tircplacas.-.--------- Number of bedrooms
Nmnberofbadlroolns Number ofhalfbaths
-- __—_-- —
Ibpe of hc;uing syaclll Number of deck.a/porehcs _—__--
'N tie orcooling ;yaclll finclo.,ed pen
1 1. "Total I'r,q;a Oyu ue Foo: I e". may be ,1111s n r,,d tol 'I'.,rA 111oiM Co,t"