6 CRESCENT DR - BUILDING PERMIT APP (002) The Commonwealth of Massachusetts
"{{ Board of Building Regulations and Standards FOR
P Massachusetts State Building Code,780 CMR,7th edition MUNICIPALITY
USE
Building Permit Application To Construct,Repair,Renovate 97 Demolish a Revised January
One-or Two-Family Dwelling ;lY' ,.1 a 1, 2008
This Section For Ofticial Use Only
Building Permit Nu Date Applied:
Signature:
Building Ca rssio actor of Buildings - Date "l
SECTION 1:SITE INFORMATION
1.1 Proper�y Address: _ 1.2 AssesAagMIh&PaYceI Nuthbers
( f� r
1.1a Is this an accepted street?yes no Map Nmh a 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 yesO
SECTION2: PROPERTY OWNERSHIP'
2.lOwvett�fRecord-
( ca-loYb&- �D C/�-LP...�I �✓ • SGl• I LI�vv yvy>r...
Name W(Print) Address for Service:
77W - aZ 8_6
Signature Telephone
'SECTION 3:DESCRIPTION OF PROPOSED WORK'(check'alhthat apply)
New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 A teration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other Specify:
Brief Description of Proposed Work':
SECTION 4:ESTV4ATEI5 CONSTRUCTION COSTS
Item Estimated Costs: OfficialUse Only
Labor and Materials
1.Building $ - I. Building Permit Fee:$ Indicate how fee is determined::
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costs(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ .;
4.Mechanical (HVAC) $ List:
s
5.Mechanical (Fire $
Suppression) Total All Fees:$
�-r� Check No. Check Amount: 'Cash Amount:
6.Total Project Cost: $ �:)t�p 0 Paid in Full 0 Outstanding Balance Due:
t ,
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 'a 7 p-7 7 Z j /c
License Number I Expiration Date
Name of CSL-Holder IIC W.Palm
List CSL Type(see below) (/—
3 Hilton Clifet
AddressSalem
Type. Description
$al em MA 01970 U Unrestricted(up[0 35,000 Cu.Ft.R Restricted 1&2 FamilyDwelling�-- Sign e ` M Masoury,Only
r Aide RC Residential Roofing Covering
ove Telep r ` WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
u D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) /y
AtlaWei
ntic, Waa11ta1�tinn r r z
HIC Company Name or HIC Regigtttant IQ Registration Number
Ul 1C.I Aye�tue `3�/
Addr�►w _
Salem MA 01970 Expiration Date
n n
Signs} Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c.152.§ 25C(6)) 1
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 a building permit.
Signed Affidavit Attached? Yes ..........e No...........❑
SECTION 79:OWNER AUTHORIZATION TO'BE COMPLETED WHEN
OWAR/'S'AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I-a"" as Owner of the subject property hereby
authorize €4!:I % G /,,� to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNERr OR AUTHORIZED AGENT DECLARATION
I, l�Yr G PCt /tin 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.
Prin[Name PA.1
Signature of Cry er or Au orized - Date
(Signedunder the pains and enalties of
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.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"