12 CONANT ST - BUILDING PERMIT APP 1 -
The Commonwealth of Massachusetts
Board of Building Regulations and Standards 'a. Y OF
Massachusetts State Building Code, 780 CMR
1016 h aV Revised Mar 201j
Building Permit Application To Construct,Repair, Renovate Or Demolis t�
One-or Two-Family Dwelling
V) This Section For Official Use Only
0 Building Permit Number: Date Applied:
1 Building Official(Print Name) Signature- Date
SECTION 1: SITE INFORMATION
^ 1.1 P opeFtyAddress: S� 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes no Map Number Parcel 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 OWNERSMP'
2.1 Owner'of Record:
Adom cRober'ts, 4{ristineM.Robert5 Salem, MA 019-70
Name(Print) City,State,ZIP
IQ Conant SFreet 978-304-a314 HKFIRoberts 1'-I oo.
No.and Street Telephone Email Address CpM
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': q u v
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ I y 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ j 057). 0 0 ❑Total Project Cost;(Item 6)x multiplier x
3. Plumbing $ 0 D. 0 0 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees: $
n Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ Il"1 0 . 0 0 ❑ Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) Q8 Z y5 3 3 ZS 1
O RI 9 AJ l 0VI9-AJ/V UCC,/ License Number Expiration Date
Name of CSL Holder
,>q 4TL n AJ77 C "E List CSL Type(see below)
No.and Street 'Type Description
Mkie 8 L EH E-&-D n4& o /p It
5 U Unrestricted(Buildings u el ing cu.ft.
_I I Restricted 1&2 Family Dwelling
City/Town,State,ZIP CP Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
781 &39 'IWO 610BP-05(10 6M61 L• Com I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
610V�FA/NVGGf P�or?s l/lIE loll yy�} z2 HIC Registration Number Expir lionon
Date
HIC Comeany Name or HIC Regishant Name
59 HTL�iy n r✓ I�VS 6�o�2bs�C mfJiL . Oohir
No.and Street Email address
A4"Rc,ettCt'->� M o,�rs ��� �39 �yo
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 ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT t
I,as Owner of the subject property,hereby authorize D 4/19 AJ Q l b V P V lO V C&I
to act on my behalf,in all matters relative to work authorized by this building permit application.
Arl M 126bets , Kctsby\.Q-Izoberts 10/19I1(0
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 ' is application is true and accurate to the best of my knowledge and understanding.
ner's or gent'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
www.mass. oq v/oca Information on the Construction Supervisor License can be found at www.mass. og v/dns
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"