42 CROWDIS ST - BUILDING PERMIT APP � fhe Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 C'MR, 7' edition OF SALEM
Revised Ju tiory
Building Permit Application To onstruct, Repair, enovate Ur Demolish a /. :tNAY
One-or tv Fomilr Owelli X
Thi<!�NticIp%ogQfrjci&I se Only
Building Permit Number: at Ap ied: b'
Signature: IkL� !6/4&,12
Building{Commissioner/Inspector or BuildingiJ Dale
SECTION I:SITE INFORMATION
1.1 Prope Add nss 1.2 Assessors Map& Panel Numbers
1.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information• 1.4 Property Dimensions:
_Si nq jF
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rem 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 es❑ Municipal❑ On site disposal system O
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of
/�,�
Name(Print) Address for Service:
978' 715 7�as
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKS(cbeck all that apply)
New Construction❑ Existing Building❑ Owner-Occupied O Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify: aip
Brief Description of Proposed Work':
p OD t ea
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011lclal Use Only
Labor and Materials
I. Building IS17200 1 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
J. Plumbing S 2. Other Fees: S
4. Mechanical (I)VAC) S List:
5. Mechanical (Fire S
Su ression Tutal All Fees:S
�1 Check No._Check Amount: Cash Amount:
6. Total Project Cost: S 17 20 V 0 Paid in Full O Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5..f1• /Licensedd construction Supervisor(CSL)
(/(//� / 014�O/Ly Licenx Number I:t imli Uate
Name of CSL• I latder I.ist CSL Type(see below)
��� Vheaoa S� L�r, i1 r. Descri ion
Add ss U tlnmiricted u to 35.000 Cu.Ft.
1A R Restricted IR2 Famil Dwelling
Signature M M Onl
�fPI Bt/Y H,sy RC Res idential Roofin Covering
telephone WS Residemiat Window anJ Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residemial Demolition
S egbte omel prove ent onI cl_VHIC) CL�J ��
�+ Registration Number
I IIC Company Name ur 111C Registrant Name
t� as
d ss W 8/ / c � spi lion Date
signatare Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a 152. 2SC(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...........O
SECTION 7n: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.
Si line of Owner Date
/ SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1 f/�/J feff 1 TFAZII ,a ex '� ,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.
Print Name S 3 )
Signature of Owner or Authorized Agent Dai
7nn
the ains and penalties of 'u
NOTES:
er who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
stered in the Home Improvement Contractor(HIC)Program), will Ug have access to the arbitration
or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
tion Supervisor Licensing(CSL)can be found in 790 CMR Regulations I IO.R6 and 110.RS•respectively.
bstantial work is planned,provide the information below:
rea(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
). "Total Project Square Footage"may be substituted for"Tolal Project Cost"