12 CLARK AVE - BUILDING INSPECTION (2) 1I� The Commonwealth of Massachusetts CITY OF�t//'y
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
w Thus Section For Official Use Only
Budding Pernut Number to-A plied '•
4D
BUildm Official= in ame)Q. =;r "4 t,,,"Ignat
$ECTIONI SITEI ORMATION K ,,., z x >:
1. operty Address: 1.2 Assessors Map&Parcel Numbers
CL,a e k &,/
L l a Is this an accepted street?yes_ no_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District - Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑
SI CTION 2:*PROI ERTI OWNERSHIP' >>
2 wnert of Record: LfVi
Nam Print) City, te,Z�IP/�� / --
GAddr�\ ess
No. and Street Telephone
SECTION 3 DESCRIPTION OF PROPOSEDW.ORI{Z(check:'all that aQply)
,, . v
New Construction❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ er of Units_ I Other ❑ Specify:
Brief Description of Proposed Work :
.)f)oz=
SECTION 4 ESTIMATED CONSTRUGTLON CO$TS1;
Y ML^4 A <y $
Item Estimated Costs. w f OfSClal Use Only
Labor and Materials >
I. Building $
1 Butld rig Permit Fa"e $ y hidwate how fe`is determined
❑ Standard Ctty(Toryn App ica,on Fee,,,,, x
2. Electrical $ ' r d"
❑Total iojeci Cost„(Item 6)krhulttpluer x
3. Plumbing
$ 2 Other Fees
4. Mechanical (HVAC) $ Ltst
S. Mechanical (Fire $
$ TotalAllyFees
Check No: , , Check Amount ?<Cash Amount
6. Total Project Cost: ' $ O ❑paid ;Full 0 Outstanding Balance Due
SECTION 5: CONSTRUCTION SERVICES
r5AConstruction Supervisor License(CSL)
License Number Expiration Date
CSL Holder
List CSL Type(see below)
. Street Type _ Description.
U Unrestricted(Buildings u p to 35,000 cu. ft.)
R !Registration
ed 1&2 Family Dwellin
City/Town,State,ZIP MMasonry
RCRoofing Covering
WS and Siding
SFuel Burning Appliances
Ion
Telephone Email address Dtion
5.2 Registered Home Improvement Contractor(HIC)
ation Number Expiration Date
HIC Company Name or HIC Registrant Name
No. and Street 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
[, as Owner of the subject grope property,hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) 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
contained i s application is true and accurate to the best of my knowledge and understanding.
k A' �R6FtlO —
Prmt ner's or Authorized Agent's Name(Electronic Signature) Date
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 can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.niass.gov.dps
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"may be substituted for"Total Project Cost"