11 CONANT ST - BUILDING PERMIT APP +tK �,gx +�7 r`u+'ar: w 3.a A ,y. �, k,WM a « '-1' 'R ."�`�}" s.Ira} 4e }'.. v •v, ` -4- -' V A 4 aa+
+a a y P , �• t ...a w. x.• xsv .. ,t"'1'`_ t r y'- 5 �+
14
The Commonwealth of MaSSaI'l1USCtt3 Y,r y `..'• ". '` ' ', s+-7 ' ''`$
} Dorrd of 8uildmg Regulations and Standards'` CITY
/( ! Massachusetts State Building Code, 780 CMR, 7 .,edition OF SALEM t s
F `• Building Peimtt'Apphcaiion,To Cud "t,Reptor, Renova a Ur Demolish a$ Revered
.One-or'Tw FumilFDwelling
Building Permit Nom ;?yµ. Thin M tion F Official AU�Only
ae' i O
Signature: « rO ��20/a
_ p ."+: • '; +Ruildi -Cammi 4 peetorof8uildmgs ._ry + „ Doe t �'cy",+-
fa «SECTION t:SITE INFORMATION
ParceNu?°I tProperty Address. 1 2 M mbes
.tee 1. I l a lsithis on accepted street? ci- 'Map Number `) ,tl.. Parcel Number, `• ( .«
F 11 3 Zo•tiin j luforinkkm ,,,�, ' l i Property,Ditneoslooa Y t b
I, ' a ;Zoning District ,.2Propoxd Use _ r m Lot Area(sq R) ;Frontage(R) "
Y ? Y t..x
I.S+BulldlogSetbab(R)c
Trom.Yard tier F..• -�.. iSiJe'.Yords ' A+:..� •' ' Rear.Yerd
' Required. Provided ' .Required iProvided :.„ Required" Provided c
• � yF y� ..° .. '.. - ... . Y r -. ,�,Y • . ' ' _. ., a Fes. a', 4.^." �� ��.F
1.6 Water Supply:(M.G 1.c.40.§ 4) '1.7 jFIood Zone Informationsj 1.8 Sewaga:D6poaal3ystem:
r
Public.Q. - Private Q. . ` Zone: .Outside Flood Zone? ...
Check if eSI3 Municipal Q,On site disposal system `D
" r r SECTION.2:a PROPERTY OWNERSNIPt * = ,` .4Tr
a Lit,Owner'of Record: ;
i 6:A Aj xc)A-) d cs
r a .A td R f��M Servicw
Z s, .� "
t� o .- r w, N.. �•Atli v.Y,�� �lr--v..,� ° � TCI prq�0 �`� ^—��....y ,�, «!'
SECTION 3:bESCRIPTION OF,PROPOSED_WORK!(cheek aU that apply)
t t- c
;NewConstmcuonQ iExistingBuildmgQ` :'Owner=Occupied D 'Repairs(s);Q� Alterations) Q' Addition,0A
d ;Demolition Q 1:Accessory'BIdg.Q, il NumberofUnita •+ Other.90 Speciy:'
r [Brief Descripti of Proposed:Work=:
e , = SECTION 4:ESTIMATEOCONSTRUCTION COSTS:'
Estimated Costs: g 011lelal Use Ua
Labor and Materials 4 ly
I:yDuildingPermit.Fee:S Indicate how fee isdetermined:
l7 Standard City/Town Application Fee
2SElsctrical, iS r
Q Total Project Cost'(Item 6)a multiplier x
3'Plumbing r S q , jwz�l
2.,'Other Fees: S _ ° t } <'
y 4.'Mechanical (HVAC) S 'List: ,
)b :5. Mechanical (Fire.Su rcssion S o' Total All Fes S.Check No 'Check Amount • ' CoshAmount 46Total-Project Coslr F0p Paid in Full' O Ouistanding:Balance Due:' }
1 � �e° .P}�R P Y�4 lr �*�n+';' x N `+ cu'y S��� �„)'t �� ' ��r Ya tY�. 8•a r � r
Y i S
«.
} � k
'�Y,),n
w e,:d '' '' r s p., " T �t i�9 AC a 3 ty" • ' s "; B« '�`�' r.h' ,tr
y"` t•-
' � 1
f`v
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Espimtion Date
Name of CSL-I folder List CSL Type(see below)
f Description
Address u 1Inrestricted(up to 35.000 Cu.Ft.
R Restricted IB2 Family Dwelling
Signature Masonry Only
RC Residential Rooling Covering
Telephone r '"` WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Regbtered Home Improvement Contractor(HIC)
I IIC Com y N- a or ll C Registrant Name Regtifiration Number
Addrea !
Expiration Date
Si 'fefephu to
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 15L f 2SC(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...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I. .4 htw" 2 b D /J&I'.4 as Owner of the subject property hereby
ori authze I U5'1-- to act on my behalf,in all matters
rely o work authorized by his building ptknit application.
�Al12�%
Si tureofOwner Date
SECTION 7b:OWNERr OR AUTHORIZED AGENT DECLARATION
ovfC;sa as Owner or Authorized Agent hereby declare
that the statements and inform re information on the foregoing application a true and accurate,to the best of my knowledge and
behalf.
Prrnt Nanic
G z- Rio
Sign re df 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 W 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 1 IO.R6 and 1 WAS,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"
i