16 CONANT ST - BUILDING PERMIT APP The Commonwealth of Massachusetts
CITY OF
�� Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 730 CMR Revised Mar 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only '
Building-Permit Number. Da Applied �)s
Si nature
ing ^` ..-Date
Build Official(Print Name) .g ,
SECTION,.1 SITE INFORMATION -
1.1 Property Address: 1.2 Assessors Map & Parcel Numbers
i6 Co
N4 S: —
1.1a 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 to Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G1 c.40,§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑
SECTION 2 , PROP ERTY'OWNERSHIP''
2.1 Owner'of Record: L� 1'1A
Name(Print) City, State,ZIP
I (. Co N�A� - -18--I-t4S- SO 1 a
No. and Street Telephone Email Address.
SECTION 3:,DESCRIPTLON OF PROPOSED WORK2 (check all that apply)
New Construction ❑ Existing Buildin Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work : 17 T-M LI? F
SECTION 4: ESTIMAT6'CONSTRUCTION COSTS
Item Estimated Costs: Offieia(Use Only-'
Labor and Materials
0 e> 1 Building Permit F.ee S !`Indicate how fee is determined:,
1. Building S rj 3
❑ Sfandad.City/Town Apphcation Fee Y
2. Electrical S ❑Total'Pio)ect Cost'(Item 6)ixinultiplier < x
3. Plumbing S O[her.Fees
Lis
4. Mechanical JIVAC) S l
5. Mechanical (Fit'e S Total All Fees: S
Suppression)
Check No. J Check Amount Cash Amount
6. Total Project Cost: S rj 3 $ 0 0� 0 Paid in.Full ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES ,
5.1 Construction Supervisor License(CSL) q k4-1 6 C _/�_/u
Ob b t� License Number Expiration Date 1
Name of CSL Holder
Q 6aQ�a 3 SZ List CSL Type(see below)
'
No. and Street Type, Descriptioa
U Unrestricted(Buildings u to 15 00 cu. ft.
. b FAO tr l R Restricted 1&2 FamilyDwellin
City/Town,State,ZIP �[ b[asonr
RC Rootin Coverin
(� W'S Window and Sidin
SF Solid Fuel Burning Appliances
U I Insulation
"Ccle hone Email address D Demolition -
5.2 Registered Home Improvement Contractor(HIC)
- Registration Number Expiration Date
HIC Company Name or I-IIC Registrmu HI is[�me
LAJ
No. Street Email address
Ct /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 APPLIESFOR BUILDING PERMIT
I, as Owner of the subject property, hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW 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.
G-zbszY � L/ -23- 13
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 i I.G.L. c. 142A. Other important information on the HIC Program can be found at
www.mass._,,ov/"oca Information on the Construction Supervisor License can be found at www.niass.gov.dr)s
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 halt baths
Type oFheatingsystem Number ofdecks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footagc" may be substituted for"total Project Cost"