5 CLAREMONT RD - BUILDING PERMIT APP The Commonwealth of Massachusetts
/l / F 'l. Board of Building Regulations and Standards CITY
OF SALEM
Massachusetts State Building Code, 780 CMR, 7t' edition
Revised January
Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
This Sego For Official Use Only
Building Permit N ber: A A Date ied:
Signature: e,YI J q / 3 /I
Building Commissioner/Inspector of ildings Dale
SECTION 1: SITE INFORMATION
. 1.1 Property Ad.dyr.ess: 1.2 Assessors Map&Parcel Numbers
�,i Cln re rt nt�l -� Scc�c m
1.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(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'
b.l Owner'of Recorr�:
.CA Ow Sof Rec 1 rnV e t.C,e C C`q sr[S r:k Ns\-- S500—
Name(Print) Address for Service:
Signature Telephone _
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check aB that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units Other -,&+ Specify: Q)4
Brief Description of Proposed Work': c % ty. r\ n r
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ j 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town 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: $ ;7 qwd 0 Paid in Full 0 Outstanding Balance Due:
1
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
f, Px tfi 11.tQ nd1 Id Q I License Number Expiration Date
Name of CSL-Holder _ J
PO ? g V Q�� � )�t List CSL Type(see below)
Ad ess � 1 Type Description
U Unrestricted(up to 35,000 Cu.Ft.)
R Restricted 1&2 family Dwelling
Signature M Masonry Only
ClY7 V1 RC Residential Roofing Coverin
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Register d tFi�me I pproveme t Coutractor(HIC)
G1enh a�CIa�lr C= c. \0L13S2
HIC Cont ny Name or HIC Registra t Name Registration Number
Pn Kr yak _, /i1t�
A re�s
���,,� Expiration 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 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, Sq, ) s Ver\c)r�( as Owner of the subject property hereby
authorize � cx 1❑ "A AQ 1) to act on my behalf,in all matters
relative to work authorized by this building permit application.
/ t TV u I
Si nature of net Date
QQ SECTIION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. f� N
Print Name nn — n^'��, —'`1
4�1 17.E 11
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of er u
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS,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 bathiooms 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"