3 CYPRESS ST - BUILDING PERMIT APP (003) c� gs � S( Ift)
The Commonwealth of Ma u NAL SERVICES
° Board of Building Regulations an a s CITY OF
L` 1 Massachusetts State Building Code, 780 CMR SALEM
�—+ g pp p 111'S Al IG L 2; '3 a Revised Mar 2011
�n Building Permit Application To Construct,Re a4Y Re Pate Ur emolish a
V I� One-or Two-Family Dwelling
n This Section For Official Use Only
t.l / Building Permit Number; Date Applied:
g/U IS
IU I Building Official(Print Nax'ne) - Signature Date
Ir LL SECTION 1:SITE INFORMATION
I`— 1.1 Property Address: 1.2 Assessors Map&Parcel Nu hers
3 ss sf. Sa Iem M 4019-70 3'q-006q -0
1.1 a Is tfiis an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
0.02? Acre
Zoning District Proposed Use Lot Area(sq it) Frontage(it)
1.5 Building Setbacks(it)
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 X Private❑ Zone: _ Outside Flood Zone?
Check ifyesj MunicipalKOn site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Maki heu) K. A� Salem, MA 01 0I70
Name(Print) — City,State,ZIP
3 Cwpre5.S 5�. q78 59N 12gy rylKall;ny @ email•cam
No.and Street Telephone ail A dress
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work :
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SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 22 56,0O 1. Building Permit Fee:$ ,.Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ 1560. 00 ❑Total Project Cost'.(Item 6)x multiplier x
3.Plumbing $ 3500. 0 0 2. Other Fees: $
4.Mechanical (HVAC) $ 100. 06 List: -
5.Mechanical (Fire $ f ^
Suppression) /!'' Total All Fees:$
Check No. Check Amount: - Cash Amount:
6.Total Project Cost: $ -7350.00 ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 m.ft.
R Restricted l&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/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 APPLIES FOR BUH,DING 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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER' 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.
Print Owner's or Authoriz6d Age ame(Electronic Signature) Date
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 can be found at
w}»v.mass.eov'oca Information on the Construction Supervisor License can be found at wwtt•.mass.�ovt, /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 ��3e� v\ �kb,J Number o hal aths
Type of heating system Number o c s/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
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