6 BRIGGS ST - BPA-14-1003 The Commonwealth of MassachusettsCEIVED CITY OF
Board of Building Regulations an�i t ttls
tt II ? al_ SERVICE SALEM
Massachusetts State Building Code, Revised thir 201I
Building Permit Application To Construct, Repair, jo�o 9,Deplisji
(J + One-or Ttivo-Fnmrly Dtvellilt II--'' 33
i This Section For Official Use Only
Building Permit Number: Date App ledr 77
AL
DuilJing Otticiol(Print Name). Signature Date
SECTION 1:SITE INFORNIATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers--lS—f%�ta�ac -moo
I.la Is this an acce Zed street?yes K no_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Propose)Use Cot Area(sy R) Frontage(It)
1.5 Building Setbacks(R)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.L c.d0,§5d) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Public❑ Private❑ Check if esO
SECTION2. PROPERTYOWNERSH10
2.1 Ownert of Record: J % -
Sy0t'I /92rrt p 0% i A/1
NZme(Prri/ii�nt) ,.City,nState,ZIP�('f/
6 /J r-i f GS' 11t. ✓7c�c r
No.m,d� Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied O Repairs(s) FAItcration(s)T#Jd I Addition ❑
Demolition pt Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Br'ef Description of Proposed Work: ®t/
3
SECTION J:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials -
1. Building S oZQ GOO 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Costs(item 6)x multiplier x
3. Plumbing S 2?Qther Fees: S
d.`Icchanical (11VAC) S List:
5.Mechanical (Fire S Total All Fees:S
Suppression)
Check No. Check Amount: Cash Amount:
6. ,rotai Project Cost: S "IWO ❑ Paid in Full ❑Outstanding Balance Due:
mray 1_ �p S-T �'Y,ram\' kco �t 12
SECTION5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS_/6A3
Jaw R N/tNl f� License Number Expiration Dale
Name of CSL holder f6/ -
List CSL'fype(see below)
Type' - - _ - Description .
No. :md Street
U Unrestricted2 Family
(Buildings an to Dwelling
cu. RJ
./✓(/'�' �(�+t+� R Restricted I&2 F:unil Dwellin
Otyfruw� M Masomy
RC Roofing Covering
WS Window and Sidin
SFI Solid Fuel Burning Appliances
OM(3109 Insulation
Telephone it dress D Demolition
5.2 Registered�Home Improvement Contractor(HIC) /'7`�10kk
/!/irY446,L- J✓ Z HIC Registration Number Expir Lion Date
I IIC Company Name or HIC Registrar t Name
No.and Street - Email address
City/Town,State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G,L:c.15L§ 2$C(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 7at OWNER AUTHORIZATI'ONTO BE.COMPLETEDWHEN.WHEN,. :,
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING.PERMIT
�t
1,as Owner of the subject property,hereby authorize mole-AIl AIJ11
t9 act on my behalf,in all matters relative to work authorized by this building perqvft application.
Xiwaf oh Mn,)Owner's Nmne(Electronih ignatu Date
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 this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorize Agent's Name(Electronic Signature) Dale
NOTES:
I. A n 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 nm 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. �oL y;! Information on the Construction Supervisor License can be found at w�v'dns
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) "A .(including garage, finished basement/attics,decks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
'fypeorcoolingsystem Enclosed Open
1. "I'otal Project Square Footage"may be substinrted for"rota Project Cost'