15 CLOUTMAN ST - BUILDING PERMIT APP (003) N
I The Conunomve:dth of Massachusetts CITY
Board of BuildingRegulations and Standards
6 OFSALEM
Massachusetts State Building Code, 730 C•MR, 7ih edition Reused Jw trary
Building Permit Application Tu Construct, Repair, Renovate Or Demolish a !• 1008
One-or Tn•u-Funnily r(!linX
1\`Itn/ gor
ection r OtTicial Use Onl
Building Permit Num erDate Applied:
Signature: Building - mldings Dale
N 1:SITE INFORb1ATION
i.l erty Address: 1.2 Assessors Map& Parcel Numbers
1Pr mz � S�
Ma Number Parcel Number
I.la Is This an accepted street'?yesJCno_ P
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use I.ot Area(sq 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided =sitcdispo�l
Provided
1.6 Water Supply:(M.G.I,c.40.§54) 1.7 Flood Zone Information: em:
Zone: ,_ Outside Flood Zone? l system ❑Public❑ Private❑ Check if es❑SECTION2: PROPERTYOWNERSH
2.Iwpe�of Recor / ,�
/(C!a (7a�
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ I Other O Specify:
Brief Description of Proposed Work': .S7'1,.p h fC /L)O F
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OMcial Use Only
Item Labor and Materials
I. Building S I. Building Permit Fee: S Indicate how fen is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier, x
3. Plumbing S 2. Other Fees: Sv 1 _ /1
4. Mechanical (IIVAC) S
List: ��J�, uV
5. Mechanical (Fire S Total Ali Fees:$
Su ression
�— Check No. Check Amount: Cash Amount:
6. Total Project Cost: S �7 7•>r ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 6& Y 'l iSolidFucl
/ /a
(/ S C� P&Ae C 4 License Numheer- Expiration Date
Name of CSI.- I Iulder.
—1 e pp(,I006e �.U,� �t/�G.+� n{J- I.ist CSL ry pe(s )�_
Address �JjlJ7�o fsDescri tion
Il t'nrestm 35pO0 Cu. F,
R Restri1°amil Eli- n
Signplu�j _ ,f— --7 hf ,bkuunOn[
�� �� �� ` RC Residetin Coverin
telephone WS ResidedowandSidi-
SF Reside Fuel Bumin Appliance Installation
U 1 Residential Demolition
5.2 Rep stere H d ame Improvement Contractor(HIC)
Af OfT �1 AtI 2 1111qC25
I IIC Company Name or HIC Registrunt Nam Re 'stmtion Number
4
Address u — Expiration D.to
Signature Telephone
/ SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 ..........O 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
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
_ SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1• S cc-`'�y 1)6-4-o C � ,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
o� behalf.
Sc* t
Print Name
///
Signature of Owner or Authorized Agent Date
(Signed under the Dams and penalties of riu
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 t o have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC to
and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.115, 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.) Ilabitable 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 (inclosed Open
3. 'Total Project Square Footage"may he substituted tier"Total Project Cost"
J