9 BOW ST - BUILDING PERMIT APPS The Commonwealth of Massachusetts
;► Boar) of Building Regulations and Standards CITY
r OFSALEM
Massachusetts State Building Cole, 780 CMR, 7 edition
Rrvirrr/Jmrnuq•
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. zix6Y
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied: jj 1
Signature:
Building Commissioner or of Buildings Dat�P'�—
SECTION 1: SITE INFORMATION
1.1 Prope Addn;: / 1.2 Assessors Map& Parcel Numbers
6
L l a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(it)
I.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided II,
1.6 Water Supply:(M.G.L c.40,§34) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public 0 Private O Check if esO Municipal❑ On site disposal system O
SECTION 2: PROPERTY OWNERSHIP'
pDemolition
r'of Record• ff nn C
, C Re L L1✓� r�G �/ f
) Address for Service:
,.,,,_ g -)s - ?ys- vac
Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
ruction O Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 �1/G
O Accessory Bldg.Cl Number of Units_ Other 0 Speciry: � l ption of Proposed Workt: Lj,. S.J S.,..
+4,e
-� �C✓� S
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OMclal Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
�. Electrical S 0 Standard Cityrlbwn Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) $ List:
5. Mechanical (Fire S
Suppression) Total All fees: S
�� Check No._Check Amount: Cash Amount:
6. Total Project Cost: S j�O 13 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervlsor(CSL) '979 7-2 1� �
I.icense Number lispimtion Uam
N of C/{ 1 hylJfr I.isl C'SL'rype Occ below) LAI
T De Description
Address U Unrestricted(up to 33,000 Cu.Ft.
R Restricted 1!2 Family Dwelling
Signature M Masonry Only
q-4- 7yY-�( RC It xidential Itoofinit Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
3.2 Regbt red Home Improvement Contract r(HIC) YD-- o g S
111(:Company Name or IIICJtegixtrartt Nume Registration Number
� s ., 151-
Add_ � Rik 7'/Y-gl Y > Expiration Date
Signature Tdephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152. 1 2SC(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...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
K& L.-I , as Owner of the subject property hereby
authorize 1w 1 11-1 to act on my behalf,in all matters
relative to work authorized by this building permit application.
R.J - (� Oaf /� eq
Signature of Owner Date
SECTION
r7b: OWNERt OR AUTHORIZED AGENT DECLARATION
�, ( 'a VV-` ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application arc true and accurate,to the best of my knowledge and
behalf. C-,) (�z ett
Print Name 6 /)C
Ali G'
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of 'u
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 gg 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 1 IO.R6 and I IO.RS,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. 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
T)pe of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
el W(
I The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
ALEM
A� A Massachusetts State Building Code, 780 CMR Sd1far
/ I�rj , Revised�Ltar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
WWW One-or Two-Family Divelling
Phis Section For Offcial Use Only
Building Permit Number D to Applied.
A .3
Building of
(Print Name) Signatuc ate
SECTION 1: SITE INFORMATION
1.1 Pro rope
Address: 1.2 Assessors Ma & Parcel Numbers
p �au� 37T 5 ✓�-cs�,v7 p
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❑
SECTION2:, PROPERTY'OWNERS1121
2.1 OwneWWr IFIn r1 ,-5
"l r
Name(Print) City,State,ZIP
a 8,5 Gt'7 t? -3/7°
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSE!)WORK'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Descr' E�ton of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
=Buildmia
Official Use Only. ,
Labor and b[aterials
$ 1. Building Permit Fee S Indicate how fee is determined:
n. Electrical $ ❑ Standard City/rown•Applicatio 1.
n Fee
�' ❑Total Project Cost'(Item.6)x multiplier x
3. Plumbing $ �o �— 2. Other Fees:'$
I. Mechanical JIVAC) S List:
5. t%fcchanical (Fire $
_tiu� ression) Total All Fees:
I�tl Check No. Chock Amount: Cash Amount:
6. 'I'utnl Project cost $ ` ❑ Paid in Full O Outstanding�- - - --- Balance Due:
.----
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL)
`J lIr"Cr7,j K �,fqM 70AJ L Number Expiration ate
Name of CSL I loldcr
List CSL Type(see below)
Tye Description
No. and Street /�
U Unrestricted Uuildia s up to 35,000 cu. [t.)
R Restricted 1&2 Family Dwellin
City/Town,S[ut ZIP /G VI orinr Ro
RC Rootin Covering
WS Window and Siding
l SF Solid Fuel Burning Appliances
7p O l Insulation
"rele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(MC)
E40 / C. HI ' to istranon N nber Expiration Date
FIIC Company Name or IIIC egistrant Nat e ,//
�dG10 e �n�Gi742✓ I�1v!
No.a r et Email"ad'drcss"
City/To ' , S ate, ZI Telephone
SECTION 6: WORKERS' COINIPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit mast 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 ........... ❑
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 I '
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print wner's N.me(Electronic Signature) v Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, ! hereby attest under the pains and penalties of perjury that all of the infoorrmation
contained in this application is true
�and
�accurate to the best of my knowledge and understanding J[ u:rt
Print wn�Autli�s Nnme(Etecu'onit Signature) / e
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 NLG.L. c. 142A. Other important information on the HIC Program can be found at
www.mass.eovroea Information on the Construction Supervisor License can be found at taww.ntass.eo�'idL
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) _(including garage, finished basement/attics, decks or porch)
Gross living area(sq. ft.) _ Habitable room count
Number of fit eplaecs_ Number of bedrooms
Number of bathrooms Number of halt/baths _
Type of heating system ------ Number ot'decks/porches
rypeOfcoolingsystent__ -- F.uclused .--_-----Open
J" `' I'Otal Project Syunrc Footage„ may be substituted du I'otal Project Cost" -- -__--
-t7_3zz
The Commonwealth of MassachuseR I�-" S�
Board of Building Regulations g�pg Ablodsll- CITY OF
Massachusetts State Building Cdde, 780 CMR 5q SALEM
��11 ` P Revised Mar 2011
Building Permit Application To Construct, Repair,�V11 Ur Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION l:SITE INFORMATION
1.1 PryyertyAddress: 1.2 Assessors Map&Parcel Numbers
Lla 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(tt)
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&3 ' Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 ne1r of Recordza: / 011 76?
Name(Print City,State,ZIP
1 VOc/ s qw'J. 17- "aql
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑T Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units I Other Specify: Dd
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:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ _424—IT
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
MAIL '512 �
`er
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor icense(CSL) /PTO Z, �� 7
License Number Expi anon Date
Name of CSL Holder
�Li���� List CSL Type(see below)
No.and Str Type Description
U Unrestricted(Buildings u to 35,000 cu.ft.
r ��- �� �'��' R Restrictedl&2Famil Dwellin
City�0� sIP Masonry M
RC Roofing Covering
' WS Window and Siding
SF Solid Fuel Burning Appliances
Insulation
Tele hone Email address D Demolition
5.2 Register Home Imp ve tent Contractor(HIC) // /l (i -�^ f
,'✓ �� i./ HIC Registration Number Expiration Date
HI Co y Nam or HI Rej�,str/ e
No. St t /1 Q�r p q�% Email address
Cr /Town,State,ZI �/ J(J 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 of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING ERMIT
I,as Owner of the subject property,hereby authorize .cJ 0
to act on my behalf,in all matters relative towork authorized by this building permit application.
Print Owner's Name(Electronic Signature) atfi
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in ths Application is true an accurate to the best of my knowledge and understanding.
Print-wner's or Authorized Ag rit's Name(Electronic Signature) ate
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(RIC)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 can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/des
2. When substantial work is planned,provide the information below:
Total floor 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
3. "Total Project Square Footage"may be substituted for"Total Project Cost,