22 CIRCLE HILL RD - BUILDING INSPECTION (4) e
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The Commonwealth of MassachuselRECEI i gERVICES CITY OF
Board of Building Regulations�8��1 A
Massachusetts State Building Code,780 CMR SALEM
5lt. i ha Revised Mar 2011
Building Permit Application To Construct,RepaillWO e m is a
One-or Two-Family Dwelling
3 This Section For Official Use Only
Building Permit Number: Date Ai5plied.
BuildingOfficial(PrintName)- Signature Dat
SECTION 1:SITE INFORMATION
1.1 Property Addre 1.2 Assessors Map&Parcel Numbers
�a c,�rfi�C_ N�7i � .
Lla 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1
Jae ��ner'o co fRerdee_f 1-cm O/97U
Sct
Name(Print) n � City,State,ZIP
�� C,e- �-e- #;// 1�C . 7ti'N-576 3
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑TTXisting
Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed o k 2:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ oC �(fb , 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/ own Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ tq f Crb , ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) Ff 79 7-7 y 93 Iw
License Number Expiration Date
Name of CSL Holder Eric W. Palm
List CSL Type(see below)
1— 3 Hilton Street
.F
No.and Street 3 1 SaleIIfW10 1970 Type Description
Sa': m MA 01970 U Unrestricted(Buildings u to 35,000 cu.ft.
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 "/�q" d/ "{ 3 I 1Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) j/ 1 L /
lU�ok�
Atl n!w Weatherization,] E HIC Registration Number Expiration Date
HIC Company N e r t ame
�� e � ue
NoT and Street Salem lA 01970 Email address
City/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 CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize t7r 1 ( _ P�iW-V7
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Uarne(Ele�ronic Si ature) 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
contai=is aati e and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent'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.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dus
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"maybe substituted for"Total Project Cost"