15 CLOUTMAN ST - BUILDING PERMIT APP z Ei % 2-i
The Commonwealth of Mor
tts
Board of Building Regulattf E$ CITY OF
Massachusetts State►Fji> �t CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, air�RepRvW W31)emolish a
One-or Two-FrJlelling
This Section For OfficiajUse,Only
Building Permit Number: Date pplied:
d
Building Official(Print Name) Signature - e
SECTION 1:SITE INFORMATION
1.1 ro erty ddre s: 1.2 Assessors Map&Parcel Numbers
I. a Is this an is
street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(11)
(� 1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Requ7aed Provided
(� 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
l Public❑ Zone: _ Outside Flood Zone?
Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 O rtofRecord: C q� ��t O� COD
!� J
Name(Print) City,State,ZIP
Gc� S� 5�S Sao 75H?, r whm(hans )$�@w
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIe(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied of Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief pescription of Proposed WI l k:
= 1 ACk / �112 le Sl
I`
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use
Labor and Materials Only
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard CityfFown Application Pee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
_ ression) $ Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 3'Coo ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Bunting Appliances
I I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State ZIP Telephone
SECTION G: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
I,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.
Print Owner's Name(Electronic Signature) 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 tot best 9f my knowledge and understanding.
1
Print Owne s or or Authorized ent's Name(Electronic Signature� Date
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 can be found at
wvnv.massgovJoca Information on the Construction Supervisor License can be found at www.mass.gov/dins
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"
• File number: 120711-22 UNREGISTERED LAND
Attorne : ATTORNEY JAMES A. PETERSON Deed Book 31415 Page 52
Lender. SEAPORT CREDIT UNION Plan Book 1001 Pa Le 300 Lots 95&97
Owner: KEVIN LOUF REGISTERED LAND
Reg. Book Sheet Lot(s):
Date: 7/13/2012 Certificate of Title
Assessor's Hap 24 Blk: Lot 165 Census Tract
MOR TGA GE INSPECTION PLAN Scale. 17^=30'
15 CLOUTMANSTREET, SALEM, MA
LOT 96 LOT 98
I )
100.0'
'1 Pool
LOTS 9 97 GARAGE
9000 S.
LOT 100
PAVED
DR.
LOT 93
b b
2 STY
#15
LOT 99
vim wip
100.0' 147' TO
STREET
CLOUTMAN STREET LAWRENCE
CERTIFICATION
I CERTIFY TO THE ABOVE ATTORNEY,BANK,AND THEIR TITLE INSURANCE COMPANY THAT THE MAIN BUILDING,FOUNDATION OR
DWELLING WAS IN COMPLIANCE WITH THE LOCAL ZONING BYLAWS IN EFFECT WHEN CONSTRUCTED(WITH RESPECT TO
STRUCTURAL SETBACK REQUIREMENTS ONLY)OR IS EXEMPT FROM VIOLATION ENFORCEMENT ACTION UNDER MASS.GENERAL
LAW TITLE VII,CHAPTER 40A,SECTION 7.