222 CANAL ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
OFSALEM
Ulf
Massachusetts State Building Code, 780 CMR, 7`h edition Revvised anuary
�l Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008
p\ One- or Two-Family Dwelling
•l This tion F r Official Use Only
lJ\f Building Permit Number: Date Applied:
•
Signature: JO
Building Commissioner/Inspector o il mgs Date -
SECTION 1: SITE INFORMATION
1.1 Property Addres : 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(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards 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 2: PROPERTY OWNERSHIP'
Or ne' f ec rd: > a n �n 1 Y() f
aiA
Po
Name(Print) A ress fj�S\ ervice:
C y 1Il
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Propose�W r 2:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building 7 b 3 0-0 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier - x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (ITVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ . 3 `'5p 11 Paid in Full ❑Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 5773,_-� Kr> 7 h 1 1
1 Zr, License Number Exp ation ate / I
Nam f CS - olde _
List CSL Type(see below) ,
Addr s Tye Description
�,/` U Unrestricted u to 35,000 Cu.Ft.)
•1 R Restricted 1&2 Family Dwellin
n T / / j ' ,Da , /� M Mason Only
`mil '-'1 04 RC Residential Roofin Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5. R iste d Home o ement actor(HIC)
51VZs (b j (oOc
I qmp NaUx Vr C R ' r t N me //��/� ` , Registration Number
A dr _ I )f —A
-� [��y Ex iration ate
atme 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 Issuanc of the building permit.
Signed Affidavit Attached? Yes .......... No ........... ❑
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 is build g permit application.
17
y'Zo to
Signature or Owner Date
/ SECTION 7b.'OWNER''' OR AUTHORIZED AGENT DECLARATION
�h f) h j, , ( �)r z f as Owner or Authorized Agent hereby declare
that the statements and infortnation on the foregoing applicatUn are true and accurate,to the best of my knowledge and
behalf.
Print a
Signa re of OwnermAilthorized Agent Date
—(Signed under the pains and penalties of erju
NOTES:
1. 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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO R6 and 1 I O.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"