16 CIRCLE HILL RD - BUILDING PERMIT APP (002) The Commonwealth of Massachusetts CITY OF
a Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised Mar 2011
4 i
Building Permit Application To Construct,Repair Renovate Or Demolish a
One or Two-Family Dwelling
This Section For Offcral Use,Qnly ;.`
Building Permit Number
a r xDate Apph w°� 4
4 ate` 70 /:2171 '
Budding Offiaal,(Pnnt Name) S�gnafure * < ',. �,'� ;a , :Date'
%
;SECTION';1 SITE INFORMATION a
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
_16 Ci cL.& " ct_L Rr�l
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(ft)
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? Municipal ❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑
SE"CTION2:;,`PROPET2TYOWNERSHIP'
2.1 Owner'of Record: c^ ^ M MA
Name(Print) City,State,ZIP
/ / Ct2ai> 9?8-7t-fS Z7 30
No.and Street Telephone Email Address
SECTION 3 DESCRIPTIO,N OF PROPOSED WORK'',(check a!]that apply)
New Construction ❑ Existing Buildin wner-Occupied epairs(s)� Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': `' T (+-c b RoD VEk d- 9.0 S220�
SECTION 4. EST IMATED.CONSTRUCTIONCOSTS
Estimated Costs: `
f
Item Labor and Materials
Official`Use Onlyx
1. Building $ Q Building Permit Fee $ a Indicate how fee is determined:,
❑ Standard Crty(Town Appliqa'tion Fee z
2. Electrical $ ❑Total'Prolect Costc(Item 6)x multiplier x'
3. Plumbing $ 2 Other Fees $ '
4. Mechanical (PIVAC) $ Lrst
5. Mechanical (Fire $ Toial'All+FeeS $
Suppression)
o Check No Check Amount as Amount
6. Total Project Cost: $ 7 3 8 O ❑Paid ih.Full :„ ,❑ Outstanding Balance Due
SECTION 5: CONSTRUCTION SERVICES
rNo. andStreet
upervisor License(CSL)
License Number Expiration Date
List CSL Type(see below)
M -Type . -Description-:
.O A b y e� '��11 t� } �� U Unrestricted(Buildings u to 35,000 cu. ft.
L� ^I R Restricted 1&2 Family Dwelling
City/Town, State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
('�. SF Solid Fuel Burning Appliances
'1-1� 33� $a-3�Q II Insulation
Telephone Email address D Demolition
5.2 Reegis'tered Home Improvement Contractor(HIC) l0 y g }` YI`r
L—P" C 'L JZ,-0L r — HIC Registration Number Expiration Date
HIC Company Name or H[C Registrant Name
? Q— 7 S�
No Street
E�C -�I'Mnp.,.��5..� i a,�3 Email address
Ci /Town, State,ZIP '-4 t L 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 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.
Print Owner's Name(Electronic Signature) Date
7this
CTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
[contained
elow, I hereby attest under the pains and penalties of perjury that all of the information
ation is true and accurate to the best of my knowledge and understanding.
e g s Name(Electronic Signature) Date
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 can be found at
www.mass.aov:%oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
Wh
en hen 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
Numer b 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"