11 COLLINS ST - BUILDING PERMIT APP u
t\� The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
/( V1 Massachusetts State Building 1 Code, 780 CMR SALEM Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Us Only
Building Permit Number: Date Ap
Building Official(Print Name) Signa Date
SECTION 1: SITE INFO TION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers es
L I a Is this an accepted street?yes_X_ no Map Number Parccl 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'
2.1 Owner'of Record:
�t chciel t a ,Jc' Salem MA y%9`7o
Name(Print) City,State,ZIP
0 .rtcs in
No.and Street Telephone Email Address 'cw 0 }tea, yy1
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) A I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2:'-tRti.,,4e ,icj n�A 1yta:�vt
1]e�» s lt-tcJleS
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building - $ 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: $ i ❑Paid in Full ❑Outstanding Balance Due:
f -
f . -
SECTION 5: CONSTRUcTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number &epiration Date
Name of CSL I folder
List CSL Type(see below)
No. and Street Type _ - Description
U Unrestricted Buildings up to 35,000 cu. It.)
R Restricted 1&2 Family Dwelling
City/Town, State, ZIP M iNlasonr
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Tete hone Email address D Demolition
5.2 Registered Home Improvement Contractor(IIIC)
IIIC Registration Number Expiration Date
IIIC Company Name or IIIC 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........... Cl
SECTION 7a: OWNER AUTHORIZATION TO BE CObIPLETED 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 [natters 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 in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Nnme(Electronic Signature) Dare
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. I42A. Other important information on the HIC Program can be found at
kaww.mass. ov.,oca Information on the Construction Supervisor License can be found at www.mass.eov:(IL
2. When substantial work is planned, provide the information below:
Total door area(sq. It.) _(including garage, finished basement/attics, decks or porch)
Gross living area (sq. ft.) _ _ Habitable room count
Number of fireplaces" Number of bcdtooms _ -----
Number of bathrooms _ Number of halt baths
Type of heating system _ _ Number of decks/porches
Type of cooling system-- --- Enclosed __---Open
Total Project Squme Footage" may be substituted for'"Total Project Cost" --
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