21 1-2 BROAD ST - BUILDING INSPECTION (3) c� tt 6 `325
The Commonwealth of Massachusetts
° Board of Building Regulationsaang WE ndd VED CITY OF
Massachusetts State Building SERVICES Reviseedd Mar 2011
Building Permit Application To Construct, Rep hhrpp�� nvnOr.DelsjD"a
One-or Two-Family Dw C ' I 33 FH'
This Section For Official Use Only
Building Permit Number: Date A lied:
Building Official(Print Name) Signature Da
^ SECTION 1: SITE INFORMATION
l 1.1 Property Address: 21 1/2 Broad St 1.2 Assessors Map& Parcel Numbers
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.Lc.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 yesO _
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Matthew Kleiderman Salem, MA 01970
Name(Print) City,State,ZIP
21 1/2 Broad St 978-590-8129 ISALESHKO@GMAIL.COM
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units I Other E Specify: Insulation/Weatherization
Brief Description of Proposed Work': Air sealing weather stripping blown in cellulose
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 3,010.49 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 3,010.49 ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS-052576 10/03/2017
James Fortin License Number Expiration Date
Name of CSL Holder U
50 Rundlett Way Lis[CSL Type(see below)
No.and Street Type Description
Middleton, MA 01949 U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP p M Masonry
i�evw�.ry ver RC Roofing Covering
UU WS Window and Siding
SF Solid Fuel Burning Appliances
978-998-4684 phil@air-tightweatherization.com I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 165640 3/15/2016
Air-Tight Weatherization,LLC James Fortin
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
50 Rundlett Way phiI@air-tightweatherization.com
No.and Street Email address
Middleton, MA 01949 978-998-4684
City/Town, State,ZIP 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 .......... EX 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 James Fortin
to act on my behalf,in all matters relative to work authorized by this building permit application.
Matthew Kleiderman 10/12/2015
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER' 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.
James Fortin 6_ ' s - 10/12/2015
Print Owners or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. 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 M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass. ovy//oca Information on the Construction Supervisor License can be found at www.inass.gov/dps
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"