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The Commonwealth of Massachusetts INSPECT ONALTKIR ICE
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code,780 CMR e �
Re�I
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Building Permit Application To Construct,Repair,Renovate Or Derritiim A
One-or Two-Family Dwelling
This S eiionTor Official Use Oni
Building=Permit Number: Date Ap Applied:'
v 6
Building Official(Print Name) Signature Date
SECTION. 1:SITE INFORMATION
1.1 P operty Address: 1.2 Assessors Map&Parcel Numbers
ra,115y \�h- �c,lemrYlAolGr7
1.f a Is this an accepted street?yes_ no_ Map Number Parcel Number
1.3 ?.oning 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.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ClOn site disposal system ❑
Public❑ Private Cl Zone:
if yes❑ P P y
SECTION 2i PROPERTY OWNERSIIHrt
Nam (Print) City,Slate,ZIP
� r'4o\ coy . q1?-'741-tD9iJ
No.and Street Telephone - Email Address
SECTION 3:DESCRIPTION'OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing BuildingJZL Owner-Occupied Ja Repairs(s) 21t Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of units_ I Other ❑ Specify:
Brief Description of Proposed Work': °I—
SECTION 4:EST IMATED.CQNSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I.Building $ 1. Building Permit Fee:$ Indicatchow fee is determined:
2.Electrical $ ❑Standard City/Towit Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other fees: $ / \\
4.Mechanical (HVAC) $ List.
5.Mechanical (Fire $
Suppression) Total All Fees:
Check No. Check Amount: Cash Amount;_
6.Total Project Cost: $
��U • ❑Paid inFull ❑Outstanding Balance Duo:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Su ervisor License(CSL) N p6n (4—Hncl\d
�'r 5(7Y1 S License Number Expiration Date
Name of CSL Holder C List CSL Type(see below)
3 1 1 Co n bra TyQe ➢esoription
No.and Street "11 - yyyy�� � ��,, 2 U Unrestricted Buildin s u to 35.000 cu.ft.
—� V G257Lr I Ii1Z��r1�U R Restricted 1&2 Fa—il Dwellin
City/1'own,S ZIP t M Mason
RC Roofin Coin
rPr — 0� 1 a t. S^A� WS Window and Sidin
SF Solid Fuel Burning Appliances
�I) I Insulation
Telephone Email address D Demolition
5.2 Registered Home I prove Rent Contractor(HIC) ' 79 9 35
t — - n e(*d 1 HIC Registration Number Expiration Date
omp y Name or H C R stranl Name
C Finail ad ro �y S
Al,d Sneer Email address
o�ceS IAA )Inv) �1-n• NISI-33�0
Ci /Town State ZIP Tele hone
SECTION 6:WORKERS'COMPENSAITION 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 7o: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENTOR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorizer Seri
to act on my behalf,in all matters relative to work authorized by this b 'Iding pe• tit application. , l
Print Owner's Name(Elec[ronic ignature) Date
SECTION 7b: OWNERr 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 knowledge and understandin .
La rf0. a/
Print Owner's or Allpiorized Agent's Nam4lRbatronic Signatu ) Date
.. . _ -
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 Q have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass. og v/dps
2. When substantial work is planned,provide the information below:
Total floor 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
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"