30 BUENA VISTA AVE - BPA-13-684 Microsoft Word-NEWPERMITFORM 1ND 2 FAMILY.doc- 1&2 Fam... http://salem.com/Pages/SalemMA_Pub]icProperties/applications/1&2...
The Commonwealth of Massachusetts
r ' Board of Building Regulations and Standards SIATLY OF
Massachusetts State Building Code, 180 CMK
r' d° EM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Tivo-Family 1hvelling
This Section For Official Use Only
Building Permit Number: a Applied•
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
.Lt Per^erh�ddress: ( /J 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 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.GI.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewa eDisposal System:
Public Private❑ Zone: _ Outside Flood Zone?Check if yes0 Municipal 'On site disposal system ❑
SECTION 2: PROP O NERSHIP'
2.1 r£fRecord• ✓ /O
one,tPsr Crty, te,ZIP !
Nam.and
7TI
No.and Street � Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Ovvner-Occupied Repairs(s) tj Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify:
Bri scription ofPropos '
1 l
Iti
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Offlcial Use Only
Labor and Mat
1.Building $ 1. Building Permit Fee: S Indicate how fee is determined:
❑ Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost' (Item 6)x multiplier x
3.Plumbing S 2. Other Fees: S
4.Mechanical (HVAC) S List:
5.Mechanical (Fire S
Suppression) Total All Fees: S
^ ,,, `V Check No. Check Amount: Cash Amount:
6.Total Project Cost: S�J/ I ❑Paid in Full ❑Outstanding Balance Due:
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SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor a(CSL A�3�//
License Number l— E`spiiabocn Dat
Name of CS Holder
om
List CSL Type(see below)
No. d Strget / Tv Description
1 U Unrestricted(Buildings up to 35_.000 cu.ft.
R Restricted 1&2 Family Dwelling
City/ o%m.State.ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
TelTel on Enjtj4ddress D Demolition
5.2 teler Hamel pro- ent C nt a r(HIC)
HIC Registration Number pim n ate
C many e o CUR_ eRi. 1 t e
No. trcd lffn_hJ Email address
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 .......... ❑ No ...........❑
SECTION 7a: OWNER AUTHORIZATIO TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACT LI R BUILQJNG PERMIT
�7
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 applica von.
, //v,
Pnnt Oumer's Name(Electronic Signature) D to
SECTION 7b:OWNER'OR AUTHORIZED GENT DECLARATION
By entering my name below,I hereW attPderafmy
ies of petjury[hat all oft a info ation
contained m this application is t d awledge and understandin l
Print Oumer's or Authorized Agent's Name(Electrons Sig na Date
S:
1. An Owner who obtains a building permit to do is/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
nmnm.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dns
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"maybe substituted for"Total Project Cost"
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