3 CROSS ST - BUILDING PERMIT APP , t
V The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
i Massachusetts State Building Code, 780 CMR, 7ih edition OF SALEM
Revised Jannory
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 2064
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Numbe / D t6pplied:
I
Signature: ?�
Built m omusioned Ins 1 i r ll i dings Dat
S TION 1:SITE INFORMATION
1.1 Property Address: I 1.2 Assessors Map& Parcel Numbers
3 C(2USS S t
1.l 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 11) Frontage(11)
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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
AlvtJt Fr-CF—W ("fz— r120S5
Name(Print) Address 1'or Service:
R
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Pro osed Work-: G/»e, 6�1,qz/9G,E
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Off vial Use Only
Labor and Materials
I. Building S 1. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S �
4. Mechanical (HVAC) S List: 'yL��
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S 13 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) 0603U 22-- '' --
�2d11
Fib O5'T 1 )y O I R15e-0 License Number Expiration Date
Name ol'CSI.•I]older --!( r List C'SL Type(see below)
//l//
r Description
Address D Unrestricted(up to 35,000 Cu.
Ft.
R Restricted 1&2 Family Dwellin
Signature G M Mason Only
9) �3� O$�� RC Residential Roofing Covering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Buming Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) 1d l '/::?6-3
HIC Company Nafne or IIIC Registrant Name / -Registration Number
ME� oS COic/ST/�UGTrrOa G� � g
Address x lav�c, r- !'u� n -f �, Expiration Dale
Signatu /v clephonnee
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.9 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. j
Signed Affidavit Attached? Yes ..........O No...........❑
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1. , 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.
Sianature of Owner Date
SECTION 71b:OWNER'OR AUTHORIZED AGENT DECLARATION
1 ,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.
S TidtlO DLO
Print N
3
Signature otowner or Authorized gent Date
(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 Sol 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 I IO.R6 and I 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"