6 CEDARVIEW - BUILDING INSPECTION The Commonwealth of Massachusetts
—� Board of Building Regulations and Standards CITY
!y Massachusetts Stale Building Code, 780 CMR, 7ih edition OF SALEM
�;✓ Revised Janaury
Building Permit Application To Construct,Repair, Renovate Or Demolish a 1. 2008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number./ Date Applied:
Signature: 1 �Buildings
Building Commissioner/Inspector ol'BuilJings Date
SECTION 1:SITE INFORMATION
1.1 Properly Address: 1.2 Assessors Map& Parcel Numbers
6 CEnpR✓Idz4LU
I.la 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 Q) Frontage 01)
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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yesO Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
/aizmAND PCLL@t' r'2 CEDHZI/i EG✓
Name nt) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': /3Emo1,,C— A-✓Vo 67c PLAGE /[/E[t/ /-?etaF'.l
nAJ E�IY-[r2E Lf�USF
SECTION J:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building S 1. Building Permit Fee:S Indicate how fee is determined:
2.Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S \ y�
a. Mechanical (fIVAC) $ List: J[ ( J
5. Mechanical (Fire S
Suppression) Total All Fees: S
00 Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S J/' o2j(,� ❑Paid in Full [3Outstanding Balance Due:
� � �� �eA-
f
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) O gO 3R 3
FAusTi y& mr' z-O I.icense Number Expiration Date
Name ol'CSL-I lolder List CSL Type(see below)
.f Description
Address u L��` �C �.�� �CA � U Unrestricted u to 35,000 Cu.Ft.
/ M-6 R Restricted I&2 FamilyDwelling
Si re �/J M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
97ff53 SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) /D 6 `9 j 3
HIC company Name or HIC Registrant Name Registration Number
��<o
Addres
1'17if 53/08,N Expiration Date
Signature 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...........0
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, 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.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
�uSTT lyo I�EGy
print No
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of 'u
NOTES:
I. 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 no.1 have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115,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
J. "Total Project Square Footage"may be substituted for"Total Project Cost"