33 CIRCLE HILL RD - BUILDING PERMIT APP (002) The Commonwealth of Massachusetts
/ Board of Building Regulations and Standards CITY
m OF SALEM
/ I Massachusetts State Building Code, 780 CMR, 7 edition RevisedJanoary
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1• _/)ox
One-or Toro-F Md welting
This Sec 'on For O icial Use Onl
Building Permit Number: D plie /
Signature:
Building Commissioner/Insp for of Buildings Dale
SECTION 1/SITE INFORMATION
I. Property Ad ress: R(2 1.2 Assessors Map & Parcel Numbers
I.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 tt) Frontage(R)
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 ifyes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
21
wn s of Cole-. tea A- � �-
ctrc e
Name(Print) Address for Service:
Signature 'relepfione
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑T Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.O Number of Units Other % Specify:
Brief Description of Proposed Work'-: r 'f G . L -0
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S Q 1. Building Permit Fee:$ Indicate how fee is determined:
�. Electrical S ❑Standard City/Town Application Fee
- ❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (FIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: $
6 Check No. Check Amount: Cash Amount:
6. Total Project Cost: S y ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 019 LJei I 27 a `
( License Number lxpiration Date
,N�,ramc of C'SL-I Iw`/ � �r l List CSL'type(see below)
e' ' e Descri lion
D Unrestricted a to 35,000 Cu. Ft.)
R Restricted 1&2 Famil Dwellinum_ ^-r� M Mason Only
U V RC Residential Roofing Coverin
Telephone WS Residential Window and Siding,
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
IctererJ Home t rove ett Contractor(HIC)
Gy 110
11) 'o -�ame 11(;Qe6jstrsat Registration Number
Q_ Expiration Date
Sib lature 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
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
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that 1he statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. (f f ��` f(� / y
/ Z I
Sig re of Owner or Authorized Agent Date
Sim nder 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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 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
3. "Total Project Square Footage"may be substituted for"Total Project Cost"