21 CALABRESE ST - BPA-13-702 The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
M
' Massachusetts State Building Code, 780 CNIR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Secton:FOr Official Use Only ..'
Building Permit Number: Date Apple i /
Building Official(Print Name) . Signature - Date
SECTION.1: SITE INFORbIATIO
1.1 Property A dre 1.2 Assessors Map Parcel ers
1.1 a Is this an accepted stye t? 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 I Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.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 yes❑
SECTION!; PROPERTY'OWNERSHIP''
2.1 Owner'of Record:
Name(Prin City,State,ZIP
r -) I � I&- -
No.and Street T Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all t ply)
New Construction ❑ 1 Existing Building ❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': �
SECTION 4: ESTEVIATED LCONSTRU T ON C STS
Estimated Costs:
Item Official Use Only, ,
Labor and Materials
I. Building $ 1 Building.PermitFee $ dicdte how fee is determined:
❑ Standard City/Town Application Fee
2. Electrieal S ❑'rotaI Project COSO. (Item6)xmultiplier x
3. Plumbing $ 2. Other Fees: $
4 Mechanical (HVAC) S List:
5. Mechanical (Fire
Sii ression) Total All Fees: S
Check No. Check Amount: Cash :\mount
6. Tutal Project Cust: S Paid in Full 0 Outstanding Bal;lnce Due:
SECTION 5: CONSTRUCTION SERVICES I
5.1 Construction Supervi�-t(! cctu L)
License JNumber Gepiatiot ate '
Name of CSL Iloh •r
List CSL Type(see below)
if T e Description
YP P
No. and Stet U Unrestricted(Buildings up to 35,000 cu. tt.
R Restricted 1&2 Famit Dwellin
Cityrrown, State, ZIP r IV[ NIasonr
RC Roofing Covering
WS Window and Siding
/ SF Solid Fuel Burning Appliances
40)
1 Insulation
Telephone Email address D Demolition
5.2 Registered Hot . Impro� meat C r
- H1C Registration Number Expiration Date
HIC C an r F •gi' , n —
No trees - / ( p Email address
Ci own, State, Z Telephone J
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be c9iNp4tited and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issua of the building permit.
Signed Affidavit Attached? Yes ..........e6 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
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name (Electronic Signature) Date
SECTION 71): OWNEW OR AUTHORIZED AGENT DECLARA IO
By entering my name below, I hereby attest n er th pain and penalties of perjury that all of the information
contai a 'n this lication is true and ac Lira to b o my knowledge and understanding.
Print Own rS or Authon-cd Agent's Name -lect unit Sign.tore) D to
NOTES:
I. An Owner who obtains a building per it 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 bLG.L. c. I42A. Other important information on the HIC Program can be found at
www.ma s.,,ovi',x Information on the Construction Supervisor License can be found at www.rnass.vov/cl
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 _
NUtttber of bathrooms Number of half/baths _
rypc of heating system -- — Number of decks/porches _-- --
1•vpe Of cooling system ------_-- Enclosed_ __.------_-Open
T. `'fotul Ptojzct Square Foo lge inay be nubitinued far"fuml Project Cost"