33 CIRCLE HILL RD - BUILDING PERMIT APP �`^ TheConunumceulthuf '\9assarhusetts ----`
1 r t hoard of Building Regulations and Standards I ( rlt
'l,� l y ,;• Massa.'llusettS State Building Code, 780 Ch1R. 7°i edition
I til'.
Building Permit Application To ('onsnurt. Repair. Reno :de (h Ih•nx,Gsb
(blr- m Tuu-lvunih Duelling
This Section For Official Use Only - -'
Bwldine Permit Nu _ --- Dale Applied: _ . ._�-S
13m ding C,rromi„i oue)i Iropccorrof BuJdu)gs
SF,CTION 1: SITF I F(`R:MA I'FON
1.1 Proper n.,.ddss: 1 ' \ssrssurs Numbers\lap & Parl Numbers
�t_r[JC fl, 11 L o�v 7 -
r M1ld 1unhu P.:nel Number
_ nu P
1.3 Laming Irfe r'�-. ut•i•. 1.4 Property Dtrncw;inns: r
- --- ---- -- 77v. Uv -
Zumngulsir:ct Pwpos,d I.'se Lot Area uq li) bn;maLc 1!1) -
!Bm Building Setback% (ft)
Front Yard tilde Yards Rear YarJ
Required Provided Requued Provided Requited Pn,vJrJ
1.6 Wv!er supply: ,.�+.:; r. -to. 3 sip 1.7 Flood 'Lone Information: 1.3 Sewage Disposal System;
Gone: Outside Flood Lime" - - llaw,<ul L+'
Puml- .tif
., f7 Private D I unmipal ❑ On%ite •.y>Iem:
_Check if yes❑
aSECTION Z: PROPERTY O\','NERSf11P' --- "--
141
N.u7� nt)) Address lire Service:�� �y �aS
o-�fc ny, nr
SEC Oh 3 D . mPrl. - `7f '1F 'r osED ` oRF•a (check all that apply) ----
r - T _
r ,nstrticti, o 0 F xlS!ri e ," Ll:.r � j uF ra� I R Pausf:i h All; , ,i'on(s) L� I \d :!inn G
F _.. _.— _...r ._ —
Demoh t. n Cr 1 Arc% soi, Bldg O j Nunre. of Unus_i� Other Sprc, ,; POo/ .ePr>14Gfr++C[4.+
d:iei' c,. ti;;n ,. [ Pr gip.::: d Wu.e'" �p�7I�C N _" �.gU✓ (272GU7�1 %�U1�� vr/ i ✓1`_
�- - - SECTION J. ESTIMATED CONS"rRUCT1ON Ct)STS-----
------ - Estimated Costs: - --�
hern !Labor and Materials) Official Use Only
1. Building $ �Q�1(J,�Q 1. Building Permit Fee: $-+It Indicate hum Icc is determined:
-" 1 ❑ Standard Citylruwn Application Fee
2. Electrical S ❑Total Project Cost' (Item G) x multiplier x _
3. Plumbing $ -1. Ether Fees: $
1. Mechanical (H\•':\C) $
i. Meehanwal (Fire Sur rraswn)
- -"------_--
5 rot,d Ali Fees: $-2+--2
/'/7 Cheek No. _Check :\m,�unc _ (•e,h .\muunl
0 Total Project Cost 5 C7V C/ Paid in Full 0 Oulatanding F3olar)Ce Due:__ _
SECTION 5: CONSTRUCTION SERVICES
S.1 Licensed Construction Supervisor (CSL) '
_--- _ Liccnse .Nunther I`.spir.wnn Date
Nance of C'SI-- IIoIJer I.mt CSI_ T\pr ter helow t
I — - -Pe c Drx ri +Wm
\dJrrss
l t luWstnr1,01.1 'Lill la :i.IN10 Cu. Ft I
R Resutreled I.\r_' F,unik Dkie16nc _
--7
SI_uauuc \I \Iawnn Unls
RC Residential Routine I. tl%ci in;`__
I rlrphunr \1'S ResiJnnial 1\'inJu�� .mJ tiding __.-__—_ ____;
SF Re,idcnUal Solid Furl liunuiir \)+�i_mrlint.dlenwn
. D — Itesidenu.il UrinulWnu
5.2 Registered Home Improvement Contractor IIIICI
HIC Company .Name or HIC Registrant Name Regtstnuon Number
Address - _ —
F.sprauon Date
Signature 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 pn-s ide
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
authority to act on my behalf. in all nlauen
i re!ative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNER' AUTHORIZED AGENT DECLARATION
1 i
as Owner or Authorized Agee[ hereby Jeclarr
that a statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name
.Sien'. of wrier or Auth rized Agent Date
IS, coed under the ❑ms and penalties of e(u o
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires tin unregistered rmitraL [kr 1
(nut registered in the Home Improvement Contractor (HIC) Program), will rtnr have access to me mbiti.a wn
program or guaranty fund under M.G.L. c. IJ'_A. Other important information on the FHC Progr:un :md
Construction Supervisor Licensing (C SL)can be found in 780(.N'IR Regulations 1 10 R6 and I I O.R5, respecli
' When substantial work is planned, pruclJe the information below: ;
Total floors area(Sq. Pt.i I Including garage, finished basement/;utics. Jerks ur porch,
Gross living area ISq. Ft.) Habitable room count
Number of fireplaces Number tit hedounns __-----_---_--_---. .
I Number of hathruorns Number of hall/haihs __-- ------_-_-__ _
hype of heating system _ -- Number of decks/ p,,Iches _-- _--__----- --
fype of cooling system _ I[I1:IosCJ
3. Total Project Square Footage• Inay be subsuluted fir 'Fowl Project Cost" _ ...
IUL-18-2007 13:31 FROd- - T-026 p 002/002 F-133
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.. Limit cad mzrv�,y con6ro2 - .. .
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Stru�tnrr.4 as locart:ed aYc. ay'rprpxL- ..
Veriri-cA+,lon by instl"UVsnt survey' -. -.
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CIRCLE HILL ROAD
1
1
Sam s rederal Credit "nion MORTGAGE INSPECTION PL AN
m THE C . i LOCAT® W
ca+voR
1 .Er!-m-v THAT ME Bu,u�w+cs a+o-oNih(� Salem .
TTLE wl. grMIER fM. OTdI T�UW.E`a� i
T?ot �ourm��.w..1I,, ED —r+E �-,'t.susztrm r�000 DE
1 FVRINtai [FFTIIY 'MAT Tii15 1'f[OPEPlY 1S n00` 'DATE' f�•^J�� 5(X - -
NA].AR.O AREA. COmmuNIT' PANEL NO.: 2 5(11n2uA(YE SUB".>LWFNT TO THE R£C(%'[>d
1NI5 G.M.tP f•N'! ,.` NOT RLSF'CN9b1L FrYt NJY IMCta'IT FF`o A,E of ME v.lESi o® of rxs-a<+n. [;fF T. rro, —
. rliAN a+E Foor rRod n+E v*coP«n uNE IT Is-Ac,vl� y�
VFIE)tE�m 9U0.pN ARS_ BE �1/.DE TO �EWFY 11iE=� IgA9JAEl_�TS .1'lnN SK. ._. -- f•A::F
�THAT A UDRE 'llr S�VEY Mfp-Uc�SS NOT
scow+. _P,ii uATtin 1.�'SR
p OJT A Rwa Ty �K( Y• wBr'cAmoR of �lR'.EY V�� qa- NOT U cTFo RUN pSept, 1.0
{ ACCQfN96.I> ONIT BY NJ AGATE.
uA Be OR PUBR
FOR FFSFcs
` 1I5 c%e.+<TIFtCAT70N TO BE'-l1•�+ED nq _ln'
Oi-FSETS_AS SHOWN ARE N ®,� F-O
USED FOR TTlE FSTAHI,SriMENT of -•,$EA^ f"� Ir
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