3 CENTER ST - BUILDING PERMIT APP tz() tv*5,lA4RN sr,
—703 — fi g 3i 5s
The Commonwealth of Massachusetts
g Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
lf
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied: 2
31 zi
Building Official(Print Name) - Signatuie Dat
I I
SECTION 1: SITE INFORMAT1
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
-23 C(:1g TcfL S7': SALEM . HA
1.1a 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(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard -
Required Provided Required Provided Required Provied 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:3
Zone: Outside Flood Zone?
Public❑ Private❑ — Check if yes❑ El
❑ On site disposal sys!-etfi
SECTION 2: PROPERTY OWNERSHIP' - t �
2.1 Owner'of Record: p
k)tLr2rD 2ocHOf l SALE A, MA _
Name(Print) City,State,ZIP
No.and Street 7eleplione Email Address '
SECTION.3: DESCRIPTION OF PROPOSED WORKz(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other Q' Specify: ROOF I NJCI
Brief Description of Proposed Work : S- MIIp A-ti19 (LG-t2C0F
SECTION 4:ESTIMATED CONSTRUCTION COSTS -
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ j'Z_ 0ov 1. Building Permit Fee: $ Indicate how fee is determined:.
❑ Standard City/Town Application Fee
2.Electrical $ s -
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $
2. Other Fees: $
4.Mechanical (HVAC) $ List -
5.Mechanical (Fire $
Suppression) Total All Fees: $
q Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ /2 Q�(� ❑Paid in Full ❑Outstanding Balance Due:
SE:N'o -To +4f3"EOuJN�->Z
SECTION 5: CONSTRUCTION SERVICES.
5.1 Construction Supervisor License(CSL)
/��/ /�/ / n ( !�(iC0 J (O'
Awr{ bty �yxuco License Number Extuiratiori Date
Name of CSL Holder
Z-3 COtxM l tlL D(L List CSL Type(see below) V
No.and Sheet Type. - Description
/�, 'n M / d/�^ 0/5/6 U Unrestricted(Buildings u to 35,000 cu.ft.
w t4 tY �VI f{ 17l v R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
5 S o- im '4coyia to l? CE7-(!1IA14P/6t1- 1 Insulation
Telephone Email address '�/� D Demolition
5.2 Registered Home Improvement Contractor(HIC) M/7
Ar.)Tt,406H Qbu(E1 co HIC Registration Number Ex tratio Date
HIC Company Name or HIC Registrant Name G �r
_7� 5T2sC.l�cclth L, 0(L A0,0VI LC.O P (7MNQl 10A),C
No.and Street (1� Email address
{4J'a�,) $AA, o 217-
Cit /Town,State,ZIP 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 ...... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN - -
OWNER'S AGENT OR C
CONTRACTOR APPLIES FOR BUILDING PERMIT
/�I,as Owner of the subject property,hereby authorize kl-rdoiy-1 O yient o
to act on my behalf,in all matters relative to work authorized by this budding permit application.
R)ILF2cy ROC46A) 2�
Print Owner's Name(Electronic Signamre) Date
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 if and accurate to the best of my knowledge and understanding.
A"Tgoeuy Nyla" 3 ZY
Print Owner's or Aut orized Agent's Name(Electronic Signature) ate
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 Homc Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. I42A. Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
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
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"