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16 CLARK AVE - BUILDING PERMIT APP The Commonwealth of Massachusetts _ Board of Building Regulations and Standards CITY i Massachusetts State Building Code,780 CMR, 7 h edition OF SALEM Revise d January (ry`� Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008 One or Two Family Dwelling Builiimg P.eriiiitiNumber. �' �5e`t,�Applied .; -LY,iW i .Signature 5� 3 Bwldng CbrmnisstoneY7)nI}lettowbf Btul " q ,�� T�toa, 1.1 Prope�Ad r s: 1.2 Assessors Map�&Parcel Numbers r/ 27, 1.1 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 1.6Water 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❑ SE4FTON s;.P3t0Pe 1"1� 31;� hiR51113ry 2.1.,/OiwneriotRecord: Nkne(Print) Address for Service: _ Signature Telephone - o SEC I 1p1V 3 DE DRIP v101V„0F RO pSE 'W©RKZ(cheek sll that'apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work2: O T W SECTION 4 EST' TEp GQNSTRUCT;ON,COSi§ Item Estimated Costs. `'4 ial'Use,Only Labor and Materials 1.Building $ 1 Budding PetvnuFgc "indicYate'haw fee is determined: 2.Electrical $ diS CitylldAtiS Applcation Fee IotaCl�ajee gSt'(Ifem6�M ngatipHer x 3.Plumbing $ ; (HYkQ, 4.Mechanical (HVAC) $ c 5.Mechanical (Fire ' Su ression $ s hotal AIIFes Cheek No:�_PNeek Amount:: Cash Amount: 6.Total Project Cost: $ �� ❑ 'ai m dull , :< ❑Outstanding Balance Due: sECTI(2N cT�xsrI „, ® sBtvls, 5.1 Licensed Construction Supervisor(CSL) '� (C-7� - [� _ _ j ]� L License Number Expiration Date" / Name of CSL-Holder V`- List CSL Type(see below) y UU P— �—, --r— a, "VEsdri,lion Address G .w U Unrestricted Lup .to 35,000 Cu.Ft. R Restricted 1&2 Family Dwelling Signature �, M Maso Only G-7�� /S—�j (3 RC Residential Roofing Covering Telephone WS. Residential Window and Sidin SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Re 'stere H_ ae I provement Contract r(HIC) Registration Number HIC Co>jtpan Name or C Reg t tt me c7 F Address / G 7 f.�-3i-2 Expiration Date Signature Telephone J SECTION 6 WORI{ERS'COMpENSATII)N INSURANCE AFFIDA�'11 (M.,G.L.a 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 ❑ SEC'I'IOJv 7a,-OWNER�IIITHOItk�ATI01!Is`G� BE)C. MRLrE 13zVYHEN pVS t!FER'.S-AGENT.OR CONT)R�GTOIt" Pd I S I()It BUSI II!i EERM)I, :authorize � ( < �� as Owner of the subject property hereby to act on my behalf,in all matters ork authorized by this buildin permitapplication. Owner Date SECTION�7,(r,`O\iFN�R�;f�,ll�� 1�, ._ ��i�AG�'I�1��LAR1T3l7N I, M ^ d Lt —as Owner or Authorized Agent hereby declare that the statements and information the foregoing application are true and accurate,to the best of my knowledge and behalf. L Print Name �i L^ '411A 1 'ma c Signature of Owner or Authortzed� Date - Si ned under the wns and penalties of pedirl 77 IvO 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(MQ 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 110.R6 and 110.R5,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 Cose,