18 BURNSIDE ST - BPA-12-1003 I'he C'ununumceahh ul'Mussachusctts
I)uarJ of I)uilJing Regulations and Standards Cl I'1' OF
Massachusetts State Building Code, 7So C'hIR
SALEM
Building Permit Application To Construct. Repair, Renovate Or Demolish a
i One-or TnvPoulin' Uu rlllr,p
This Srctiun Fur Official Use Only
Building Permit Number: Date Applied:
- to
lluilding 011icia (Print N,une) Si iature Date
SECTION I: SITE INFOR ATIO
1.1 Pro erty Address: 1.2 Assessurs Slap di Parcel Number
Ls� �OMSiGIC' S�
1.I a Is this an acce led street? es no NI:rp Number Puree! Number
1.3 Zoning Information: 1.4 Property Dimensions:
/uning District Propowd Use Lot Aura(set II) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.t.c. 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood'Zone? Municipal❑ On site disposal s)slum ❑
Check if us❑
2.1 Owne t of Re�or SECTION 1: PROPERTY OWNERSHIPt
/4naelre. Mellem -W2(k-k A U!9`70
N�une(Rdm) Uq•.state.!.I
No.and Street rotephune Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairsls) ❑ Alteratlon(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ .Speeil'y:
Br Description of Proposed Work=: 2Q Q QW s k; Aep v otW
�v6r InLl I E� 6c t'l ovx
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 0111c1u1 Use Only
Il.abur;utd .\Iaeriab) Y
I. Duilding S /a 00 1, Building Permit Fee: S Indicate how fee is determined:
i ' Flectrical ❑Standard City:Tuan Application Fee
❑Total Project Cost'I!tern 6)x multiplier —.. .x
i i, I'IumMng S '. Other Fees: S - --- -
4. .\lech.11lic,11 IIII, '! List:
\lochanicai II'ire ,�- -- ----- ---------- -- - -- . . .
o Total Project Cusl: S /� (JL] ('heck \'u. _ —Check:\runt!!: . _.-._ (',uh \iuo ill:
❑ Paid in Full Cl Oatstandin lalarce Out::
L/
tiE<"PION S: ('ONSI'Rt�C'fION tiF:RVI('b:5 e
i.l C'onstructiunSupenisurLiceusel�yl•1 �,��Ud� _ � oZ �j3
:'w I Iconic Nunthcr I't irai�n Dule
Nnc,11,0l. llne lt l iitCSl. l)peliechelowl._�.} '--- —
Descriplion
q'i-and Street G� ( 1 ,,reslrictcj 111,
id, .s li 11 1S,Iltlt eu. it.)
N ItearictcJ I:h2 Pamil Dwellin
%I \loslnl
Ciyrl'ati n,\lute.LII
it Hlwlin Cucerin
Nk's WinJua:wJ SiJin
SF Solid Fuel Ilurning Appliances
Insulution
I[maiI;IJJrci+ U Demolition
'fcle hone /
4,2 Registered `lllome Improvement Contractor(HIC) Set o�j 6 02 a�
cz pq ni#S• ro—c t cy—% I IIC IIcgistrniun Number '. pin tiuu Dute
I IIC'unl any N;l+''g or I IIC la•yistral allm�
$FrCan T � L'mull aJJresy
IrkYbltru
etqJl M/4 odcd-
C( /Town, State, I rele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. I57. S 2SC(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 IssuariccarMhe building permit.
Signed Affidavit Attached? Yes .......... No...........O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building p it application.
Q„aela 3e(levil �� S S- Oqc)
Dfite
prim Own• s Nwne(Elccwnlc Slgnulan:)
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.
Print l)wne nor:\uthmiieJ:\gent s Nonw ICleuronlc Slgnawal
Dole
NOTES:
1. o do his.her own work,or an owner who hires an nrcgistered contractor
An Owner who obtains a building permit t
(nut registered in the Hume Improvement Contractor iHICI Programl, will LLoj have access to the arbitration
program or guaranty I'und under I.G.L. c. 1 J?A. Other impunant information on the HIC Program can be found at
"A information on the Construction Supervisor License can be found at 111•1,' �" dil,
\\'hen substamial work is planncJ, protiJe the inlonnation below:
fold flour area a nti R.I - _—__.._1 including garage, finished basement attics. Jocks or purdl I
Gross lit ing area ut. It.l __.
Habitable room count
\wmbcrot'lircidaccs Nunlberofbednwnu
\umherol'hathrooms - -- \uberut'hals,po
I\pc of he.lting s)acnl _ \umber oi'Jaks parches
� 11 pl ot h't'h llg i\ftelll
Enclosed ,Open
llleJ firt 1111:11 l'rUjeCl Cost—
"f ol.11 Project Square Footage 111m he iklbnlli '