14 BURNSIDE ST - BPA-12-755 �r-_ ---
� j I'he C'omnwntvcahh ul'tifassachusclls
y; l� Board of Building Regulations and Standards CITY OF
r �:�
Massachusetts State Building Code. 7SO C'NIR SALEM
Building Permit Application To Construct. Repair. Renovate Or Dernol' a
One-or Two-k'u till' Dr rllirg
This Section For Otrcial Use Oal
Building Permit Number: Date A He
3 Zv l
Building 011icial(Print Marc) fSignal 1 ale
SECTION 1:SITE INFORMATION
I'/l 7e�jS,���S/`� 1.2 AssessorsAssessorsSlap Sa Parcel Number
I.1a Is this an acce ted street? ,es no Mart Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Imposed(No Lot Area(sy 11) Fmnluge(Il)
1.1 BuildInQ Setbacks(R)
Front Yard Side Yards Hear Yard
Required Provided rcd Provided Required I'roviJeJ
1.6 Water Supply:IM.G.1.c.40.§Sa)[,:17:21ood Zone Information: 1.3 Sewag*Disposal System:
t§ablic O Private❑ one: _ Outside Flood Zone? Municipal❑ On site disposals)stem ❑
Check if es❑
SECTION2: PROPERTY OWNERSHIP'
2.IQK>M° lZe� 0Dq-) SUlem mass Ol�r7o
Ng ow(Print]—� ('i)•.Stalc.I.IP
�g M 22M/ 2 #3 98 40/- U ICI ire y Soso iZ y
Nu.and Saecl relephone &nuil Address �m
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(%) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of lJnits_ Other ❑ Spccil'y:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and .\Iaterialsl y
1. Building S 1. Building Permit Fee: S Indicate how Ire is determined:
'. Electrical S ❑Standard CityiTu%w n Application Fee
❑Total Project C'ostt(Item 6)x multiplier
I Numbing S , Other Fees: S -
J. \iedt.ulic.d ill\.\(') 5 List:__ --___ _ // 1
3. Ni",
lech.mic it I Fire
tit +res.ion) S rotal .\II Fces: S_ —
Ctic" No. Check :\mount: _ Ca5h \mount:
r, Total I'rnjcct Cost: S 13 ❑pyid in Full ❑Outstanding 11aEutce Due:
,
SIA I'ION S: CONSTRUCTION SERVIUF.S
5.1 (•onstruction Supervisor License(('SL)
I iccnse Nwilhcr
\aorta ul'l'.Sl. l hddcr
I is t'SI. Il le Ixee
No. .utd Street
"-----._.-'----...._—_ --- I)PC Description(n IhlrestricicJlDuiWin's tin 1%115,IIII0n1. 11.1
R Re,tricted 1&2 Famil Ih�cllin
C'itslfoen.Al;ne./11' . . M Slason
RC Raclin 0,%erin
_ R'S W'indow,ind Sidin
SF Sulid Fuel Ruming Appliances
I Insulation
Pale hums Finail address D Demolition
5.2 Registered Home Improvement Coutroctor(HIC)
IIIC'Itegistr;ltion Number livpirntiun Date
I IIC C'ompun) Name or IIIC Itegistrunt Noire
No. aid Street Email address
City/Town.State ZIP fcle hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 25C(6))
Worker Compensation Insurance affldavit 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 Affldavit Attached? Yes ..........O No...........O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application,
Print Uwnar's Nwne(Ekcwnic Signumrc) Date
SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION
LABlyetg my name below, I hereby attest under the pains and penalties of perjury that all of the information
in this application ' true and accurate to the best of my knowledge and understanding.3 20 2r's or:\uthuri, Agent's� unc IF.lactranic Signature) Data
NOTES.
70%�nerr who obtains a building permit to do his.her uwn work,oran owner who hiresan unregistered cum ractur
ered in the Hume Improvement Contractor IHIC) Program),will nu have access to the arbitration
r guaraty fund under\I.G.L. c. 14_'A. Other important information on the HIC Program can be Iltund at
. �•� •-,.1 Inforntalion on the Construction Supervisor License can be found at It o.� no.t. i;n ,III.
2. stantial Iwrk is planned, provide the inl'ormatiun below:1 sy, t1.1 . _ _.._I including g:vagt, lmished basement attics.decks or porch)
Gross liv ing area I sq. I1.1 _. — habitable roust count
\unthanl'liraplacas ... Numberol'bedroonls
\umber al'halrounu \umber of half haths
I')pc of heating s),Icnt _ \lumbar ol'decks• porches
I
I'\pa I'I Coallllg i1 ilelll title losdJ ( I en
1, "11u.1 Project Square 1:001aya" ma% he substiu ted liR"1'otal Project Cost-