158 BOSTON ST - BPA-11-381 5
(0/i e o
The Commonwealth of Massachusetts CITY
Board of Building Regulations and Standards OF SALEM
Massachusetts State Building Code, 780 CMR, 7i6 edition Revised Junuury
Building Permit 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: O Z
\J Signature: J &A
Building Cumm sioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
11.11 Pro erty Aess: 1.2 Assessors Map& Parcel Numbers
47CaS`7'ov ST
I.la 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 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
t.6 Water Supply:(M.G.L c.40,§Sa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record: 9�
GuY 7 v sc t h 1 0i3r2
Name(Print) Address for Service:
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Buildin wner-Occupied ❑ 1 Repairs(s) Iteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units - Other ❑ Specify:
Brief Description of Proposed Work'-: t
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 City/Town Application Fee
2. Electrical s ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: s
4. Mechanical (HVAC) S List:
5. Mechanical (Fire s Total All Fees:S
Su ression
M Check No. Check Amount: Cash Amount:
6.Total Project Cost: s o b SO t, ❑Paid in Full ❑Outstanding Balance Due:
I
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
c-6,":A4 Licenx Number Expiration Date
Name of CSL. Holder
1 �4 aLM A t� _s—L —E'P<dba List C'SL'rype(see below)
�!
.4JJrc rs pe I Description
U Unrestricted(up to 35.000 Cu.Ft.
- - R Restricted 182 Family Dwelling
Signature
M Masonry Only
RC I Residential Roofing Covering
Telephone WS I Residential Window and Siding
SF I Residential Solid Fuel BuminitAppliance Installation
D I Residential Demolition
5.2 1{eghteredHerne ��e%Contractor(HIC) � � l
— a r L T • 1
I IIC Compan Name or HIC-Regitrant N• Registration Number
19 (hA;v Addre �,23-- /
ss
�_�-� 5 Expiration Date
�f ��' � � 22 31g�4
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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...........O
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 matters
relative to work authorized by this building permit application.
Si atureofOwner Date
SECTION 7b:: O�WNERt OR AUTHORIZED AGENT DECLARATION
6:1 as Owner o uthorized Agen ereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
I
Pnnt Name
Signature of Owner or uthoriud A en Date
Si ned under the pains and penalties of 'u
NOTES:
I. An Owner who obtains a building permit to Jo his/her own work,or an owner who hires an unregistered contractor
(no(registered in the Home Improvement Contractor(HIC)Program), will a[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 1 WAS, respectively.
2. 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 halfYbaths
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"
l