3 DALTON PKWY - BUILDING PERMIT APP a The Commonwealth of Massachusetts CITY
Board of Building Regulations and Standards OF SALEM
Massachusetts State Building Code, 780 CIVI Tn edition ilvwsed Jonnury
Building Permit Application To Construct, Repair, Renovate or Demolish a
1. J(10,Y
One-or Tiro-Family Dwelling
Thi 'ection For Of)icial Use Only
Building Permit Number: Date Apph d: 'L
Signa ure:�-- — -
Building ommissioned I •t I' 1 p Oute
T ON I: 1• E INFORNIATION
1.1 Pro erty ddress• 1. Assessors Map& Parcel Numbers
r \Pry
M Number Parcel Number
I.la Is this an accepted street?yes u_ no_ P
N3 Zoning Information: Property Dimensions:
Zunin`- Pmpused Use Lut Area(sy 11) Frontage(11)
lS
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
RcyuireJ Provided Required Provided liequircd
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? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 AwnR rt of Record:
4 hdty lccice
Nome(Print) Address for Service:
Signature 'relephone
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building� Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.Cl Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': el ok
�
rP i. C r�Cl S•h i '
& .l 4E zaar ong:�!
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials
I. Building S 4p,. I. Building Permit Fee: S Indicate now lee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S �� J�
4. Mechanical (IIVAC) S List: r✓ - T
5. Mechanical (Fire S Total Ali Fees: li
Su ression
Check No. Check Amount: Cash Amount:_
6.Total Project Cost: S ❑ Paid in Full O Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5,1 Licensed Construction Supervisor(CSL) - eq A<�O,q ZZ
License Number Pspim0un Dale
Nto ol'C'SL-I IulJer List CSL-I'spe(see Mow)
`07- r^ (gwf7ti,Ct S'k
Address I's Description
SS)Pw\ Il I!nrestricted(u2 to35.000 Cu. Ft.)
Si•nature l Restricted 1&2 Family Dwelling
M I k1usunry Oni
�1 RC' Residential Roulin Coverin
Telephone WS Resideniat Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registere6l1ome Improvement Controctor(HIC)
aTL Pvv�rcIs ccr.�rgc
t+t1\• �
IIICCmpanyNamorCRegistran Nwe -- t D i
r
( Pt I „ Fw\Address l/ �l c.p� �
,r p �p c-11�I Grp�uun Date '
" naTurc "refcphone • /
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 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 .......... O No...........O
SECTION 7a: 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.
Signature of Owner Date
SECTION 7b: OWNEW 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.
Print Name
Signature of Owner or Authorized Agent 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 no 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 IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total flours area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Ilabilabie room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half7baths
Type of heating system Number of decks/porches
TNpe of cooling system Enclosed Open
3. "Total Project Square Footage"may he substituted for"Total Project Cost"