9 CIRCLE HILL RD - BUILDING PERMIT APP , The Commonwealth of Massachusetts CITY
Board of Building Regulations and Standards,h OF SALEM
t/ Massachusetts State Building Code, 780 CMR, 7 edition Revised✓antuiry
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 2008
One-or Two-Family Dwelling
/ This 50ion For Official Use Only
Building Permil Number: Date Applied: V v
Signature:
O
Building Commissioner/Inspec of Buildings Date
SECTION 1:SITE INFORMATION
I.l Property Address: 1.2 Assessors Map& Parcel Numbers
t ,r 1-1 . L I `2n
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 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I,c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flaod Zone? Municipal Cl On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownerl of Record:
10 � /AA. n o we c1 C
ipvh L. +
t2cLu 1\.LL �n
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cbeck all that apply)
New Construction❑ Owner-Oc
Existing Building cupie Repairs(s) 1� Alleration(s) 13 Addition ❑
Demolition ❑ Accessory Bldg.❑ I Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': S T—rz. �2 hln Ce `b-- 1'-;.A re ACtC-- IREMPEK 'C
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ I. 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 S 2. Other Fees: 5
4. Mechanical (11VAC) 5 List:
5. Mechanical (Fire 5 Total All Fees:S
Suppression)
/ q Od Check No. Check Amount: Cash Amount:
6.Total Project Cost: S b 18 lJ - 13 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) l t ,A� ��
� 'i 3 114- 1
1 V06blX-/S License Number Expiration Date
Name of CSL-I Ioldcr ,n
f y Cl 01A t� �Y— ?,OA SUE]AV List C'SL'fype(see below)
AJJrcs T Description
Ft
U Unrestricted u to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwellin
Sig afore r�� M Masonry Only
RC Residential Roaring Covering
Telephone WS I Residential Window and Siding
SF I Residenlial Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 egistered r
a Impro;!Is t Contractor(HIC) Doak (
HIC Company Name or 111C Regis t Name Registration Number
1 `4 4/Yl A t a ��c— P.e� bnal�
AJJrr�s__ Expiration Dale
Signature�3� TJele�ptiune
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 ..........O No...........O
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.
Signature of Owner Date
1 SECTION 7b: OOWNEW OR AUTHORIZED AGENT DECLARATION
L 1 Lp LY ( n+iT- ,as Owner o Authonzed A ent ereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
,::S C � — 10- 1COS -
Signature of Owner o ut oriz a Date
(Signed under the pains and penalties ofperjury)
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 gpl 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 1 IO.R6 and 1 IO.RS,respectively.
?. When substantial work is planned,provide the information below:
Total Boors 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"