16 CROMBIE ST - BUILDING PERMIT APP (002) 1
The Commonwealth of Massachusetts
air Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
J Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Divelling
This Section For Official Use Only
Building Permit Number: "
Building Official(Print Name) 'Sign at „ - - Date
SECTION) RNIATION
1.1 Pro rff dress• 1.2 Assessors Nla &Parcel Numbers
V M Cy'►���� 2 P d e s 3
I.la Is this an accepted street?yes 1 no Map Number Parcel Number
1.3Z oning Information: 1.4 Property Dimensions:
Zuning District Proposed Use Lot Area(sq ti) 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:
I'ublic❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP!
2,1 Ownert of Rec /� 1�1/0 �
1.�� ._ Jg( fir! V
me(Print) City,State,ZIP
6 6 ✓0 rvr h 1 e 5
No. mid Street Telephone Email Address
SECTION 3. DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction ❑ Existing Building Ef, Owner-Occupied &I Repairs(s) Alteration(s) Addition ❑
Demolition Accessory Bldg.❑ Number of Units Other ❑ Specity:
Brief Descript/ion f Proposed Work^ l
SECTION 4: ESTINIATED CONSTRUCTION COSTS
Estimated Costs:
Item Labor and Official Use Only
Materials
1. Building $ I. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee..
❑Total Project.Cost'(Item 6)x multiplier- x
3. Plumbing $ 2. Other Fees:
4.Mechanical (HVAC) $ List: . / C . +-
5. Mechanical (Fire $Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 26 DO(J ❑ Paid in Full p Outstanding Balance Due:
l
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) e 5 07707 C(
Tv1te-S ) C -/e /f G47 License Number E.x iration ate
Nance of CSL Holder
List CSL Type(see below) U
164,<e l�S Type Description
No.and Street
n w'� / -n R Unrestricted2 Family
(Buildings u el ing cu. ft.)
f7[z fy V �i �/�/�/ �" / ° R Restricted I&2 Famil Dwelling
City(fown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
// SF Solid Fuel Burning Appliances
9�7s- ctZa G�Z64f Gf/ z-V o@/ i.� 1 Insulation
Telephone Email address D Demolition
5.2 Registered Hom 1 prr
�4 ff vvement Contractor(HIC) 3 Y j/
I/ (�;C HIC Registration Number Expiration Date
HlVoePn�Iytmc or HICRegistrant Name
Nojid Street Email address
6t /Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M:G.L.c: 152. g 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'
I,as Owner of the subject property,hereby authorize Dz,.,o f J 1& Vsaz-,
tg act on my behalf,in all matters relative to work authorized by this building permit application.
� G �+ w fg_-+ L •,II.� X / `Ll/� ?
Print Owner's Nance(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED.AGENT DECLARATION,
By entering my name below, 1 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. -
5wa,e,5 y L 1"4;04 —� Da[e K/_2 VD0
Print Owner's or Authorized Agent's Name(Electronic Signature)
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.eOntractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under 1A.G.L.c. I42A. Other important information on the HIC Program can be found at
www.mass.gov.'oca Information on the Construction Supervisor License can be found at www.nmss'.cov/dPs
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 Projec Cost'
32'-6- i
2,343 S.F.
ASSESSOR'S
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33' NO. 16 {
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y\� CROMBIE STREET
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TO: NORTH SHORE BANK, A CO-OPERATIVE BANK MORTGAGE PLOT PLAN
1 CERTIFY THAT THE DWELLING SHOWN IS LOCATED ON /N i
THE GROUND AS SHOWN AND CONFORMED TO THE
ZONING SETBACK REQUIREMENTS FOR SALE,M. MA AT
THE TIME OF CONSTRUCTION, OR /S EXEMPT FROM SALEM, MA
t40LATION ENFORCEMENT UNDER M.G.L. TITLE I
CH. 40A SEC. 7. DATE.- 7126113 SCALE 1" = 20' JOB. NO. 97155927I
NOTE - THIS PLAN WAS PREPARED FROM LANDMARK
A TAPE SURVEY AND IS INTENDED FOR
MORTGAGE PURPOSES ONLY. OFFSETS ENGINEERING & SURVEY/NG, INC.
SHOWN ON OR SCALED FROM THIS PLAN 583 CHESTNUT STREET
ARE APPROXIMATE AND SHOULD NOT HE LYNN, MA 01904
USED TO DETERMINE PROPERTY LINES (781) 592-7016