20 COLUMBUS AVE - BUILDING PERMIT APP � Phe Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 71h edition OF SALEM
Revised Jonuors'
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 2008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Signature: t,5-i
Building missioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
I.1 Property Address 1.2 Assessors Map& Parcel Numbers
(ayn6tcl klrl�
I.l a 15 Ihis an accepted street?yes i/ no Map Number Parcel Number
IJ Zoning loformation: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Require) 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?
Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1,Ownerl of Record: ry /
es Ave-
Name(Pei t) Address for Service:
-
Sign '✓ Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) Url Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work'-: 7" a$p
S+R r13 a nl C—� ine m-ve 4 ftnrlr ac ti nld 'd
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S �S S+r7a- ' I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S l� biM! 0 Paid in Full 0 Outstanding Balance Due:
SECTION S: CONSTRUCTION SERVICES
5.1(Licensed Construction Supervisor(CSL) p
License Number l:.rpinnion Date
Name of CSL-I IulJer List C'SL'Iype(see below) U
fype Description
Address U Unrestricted(up to 35,000 Cu.Ft.
R Restricted IA2 Family Dwelling
Signatu /t� M Mason Only Gf RC Residential Routing Coverin
Telephone V Residential Window and Sidin
/3 Z Z- SF Residential Solid Fuel Burning Appliance Installation
D _ Residential Demolition
5.2 Regbtered riome lmproveineof Contra--A (HIC) vs-rV�
�M Registration Number
l uc Co xir()f�o/dl�ytNG e 'N' `IJ PA
-7 — Z/ —/U
Address .L 2Z Expiration Date
3 rL f�I�Pl�6!/}N I Sf 2+.±e� .t 9 off�$/3
Signutu G 'felephune
SECTION 6: ORKERS'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...........❑ 6�
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
author'z to act on my behalf, in all matters
relative t6 work authoriz d by this building permit application.
x art,✓ AD /77^ 2d
_qi6At6mofO wner Date
J SECTION 7b: /Of WNEW OR AUTHORIZED AGENT ECLARATION
1, 917 r 2 �} 31j9.4. LTK ,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
behalf.
(d r_
Print ZZ
Signature of Owner or 66thoriZCO Agent Date
(Signed under the pains and penalties of 'u
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 goj 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 I I O.R6 and I IO.RS,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 Cost"