31 COLUMBUS AVE - BUILDING PERMIT APP (002) Y' the Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
t m OF SALEM
/� CI Massachusetts State Building Code, 780 CMR, 7 edition RevisedJunuary
(I
Building Permit Application To Construct, Repair, Reno ate Or Demolish a i. '//08
One-or Two-F imil_v Dwelling
This Sec cm INr Official Use Poly
Building Permit Number: ate Appli (f
Signature: C
Building Commissioner/Inspector of Buikti gs Date
SECTION NSJ# INFORMATION
1.1 Pro e y Ad ress: 1.2 Assessors Map& Parcel Numbers
z Q, -
1.1 a Is this an accepted street?yes-1/ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(It)
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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check ifyesO p P y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record: S 9 Sfi-
lJ
Nam Fin Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Afteration(s) ❑ Addition ❑
Demolition Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work-, [+-Q
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 00-0 0 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: �S
4. Mechanical (BVAC) S List: � mil// it d
5. Mechanical (Fire S
Total All Fees:
Suppression) $
Check No. Check Amount: Cash Amount:_
6. Total Project Cost: S 3 poo, ()d ❑Paid in Full ❑Outstanding BalanceDue:
I
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Nance of CSL-I(older
List C'SL'1'ype(see below)
AddressF e Description
lJ Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature M r0asonry Only
RC Residential Rooting Coverinit
felephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature 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...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, b Pro(1, �!Kew CTT�K as Owner of the subject property hereby
authorize _ �/IQ U _Pe, - __ ._ to act on my behalf, in all matters
re a rvf e t wor orized b build_—ittit application.
Si nature olOwner Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
1, ,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.
Print Name
Signature of Owner or Authorized Agent Dale
(Signed under the pains and penalties ofperjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I0.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 Cost"