41 CIRCLE HILL RD - BUILDING PERMIT APP r : ; ' Ck '1 S8
The Commonwealth of Massachus9 . ' {'t ,f';. CITY OF
i Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780Z%II§CT 20 P .3 I.&Wd Alar 2011
t Building Permit Application To Construct, Repair, Renovate Or Demolish a
. PP
9 One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Dote Applied:
OuildingORicial(Print Name). -: . . , Signature• '.. . Date
I SECTION I:SITE INFORMATION
1.1 Property Addre 1 � (1 1.2 Assessors Map&Parcel Numbers
W 1 C (rrl 16� l�(X
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(sy ill Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Reyuirod Provided Reyuired 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 Zoo e7 Municipal eon site disposal system ❑
Public B' Private❑ Check if esB� p po y
r ,SSECTION 2: PROPERTY WVNER'yS.rHHI,P!
1/
VIA
t��me(Print) ,� n City,State,ZIP ,
41 Cord�n (�,1( 1Cdl ti`tPr��lo-�!o() ad•eon
No.and Strut Telephone v Email Address
SECTION 3: DESCRIPTION OF PROPOSED 1YORW(check all that apply)
New Construction❑ Existing Building❑ Owner•Occupied ❑ Repairs(s) ClAltemtion(s) ❑ Addition
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed 1Vork2: i
3 �
SECTION 4: ESTGNATED CO, STRUCTION COSTS
Estimated Costs: Official Use Only
I tent Estimated
and Materials)
1. Building ; 5 O vU 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S 5 t7 ❑Total Project Cost?(item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4.Mechanical (HVAC) S List:
>.::\[cc hanical
Su ressi (Fire fatal All Fees:S
mt)
G Check No._Check Amount: Cash Amount:_
6.Toi:d Project Cost: S 15 ) �UU ❑Paid in Full ❑Outstanding Balance Due:
IDIz .J oz"t�L->✓'o C . C. FpfZ, F/0
( 'L-AI-4 S i r-) P+ Utz lbw Tz 20 14
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) � OB �19)
.R 'k License Number Expiration Date
Name of CSL Holder List CSL'rype(see below) V
Type - - Description
No. midi Street / U Unrestricted DuilJin s u -to 35,000 cu. Il.
� j.ip/(•,� r r(�, Y rJ R Restricted 1l2 F;unil Dwellin
City/Town,State, IP M Masonry
RC Rooling Covering
Ws- Window and Sidinst
�X� lJo/t�Yn SF Solid Burning Appliances
( Insulation
Telephone Email address D Demolition
5• Registered
I Home
pU C m/ent on- tcnctor(Hlrr G`I 1-11;119i
HIC Registration Number Esptretion Date
II`C„ myh om or I Registrant Name r1 1 `'
o.mtd Street d (�" U�q_11*' Em it address
Ci /Town State ZIP Tele hone UO
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 Wtiance of the building permit.
Signed Affidavit Attached? Yes ..........P" No...........O
SECTION 7a:OWNER AUTHORIZATION,TOBE.COMPLETEDWHEN, -';:
OWNER'S AGENT OR CONTItk&OR APPLIES FOR BUILDING PERMIT`
1,as Owner of the subject property,hereby authorize 7
t9 act on my behalf,in all matters relative to work authorized by this building permit al
lication.
PrOwner's N iure Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Dale
NOTES:
I. An Owner who obtains a building permit to Jo his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will nu(have access to the arbitration
program or guaranty, fund under NI.G.L.c. 1 d2A.Other important information on the HIC Program can be found at
ww.v nrtss eov:'ocn Information on the Construction Supervisor License can be found at wwa•.mass. ov:'dns
2. When substantial work is planned,provide the information below:
'rotal floor area(sq. RJ (including garage, finished basement/attics,decks or porch)
Gross-living area(sq. R,) 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 ofcoolingsystem Enclose) Open
J. "Ibtal Project Square Footage"may be substituted tar"rota Project Cost"