7 DALTON PKWY - BUILDING PERMIT APP Alseif dd
' The Commonwealth of Massachusetts CITY OF
� Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Family Dwelling
= This Secfjon For OfffciaLUse Only
Building Permit Number Date' phed
w1 �'
nature , Date
Si
Building Official'(Pont Name) g
SECTION 1 SITE INFORMATION
1.1 Pro eit y Address: 1.2 Assessors Map& Parcel Numbers
7 1the1/
Ma Number Parcel Number
i.la Is this an accepted street?yes_ no p
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.O.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 yes❑
SECTION 2:: PROPERTY'OWNERSIIIPr.'
2.1 OwnertofRecord: � /FM 2 oi97 �
Name(Print)
City, State,ZIP
�ei�� �ove �er 979- &-q9 51�
No. and Street / t Telephone Email Address
SECTION 3: DESCRIPTI N OF.PROPOSED WOBd42(check all that apply),.-.
New Construction ❑ Existing Building Cl Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ I Accessory Bldg. Cl Number of Units_ I Other ❑ Specify:
Brief Description of Proposed WorkZ: T i N S U !h t 4 h C / St, A 07
lr s P eaded
SECTION 4: ESTIMATED CONSTRUCTION_COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
1. Building $ lT O I Bulldliig Perinit,Fee $ Indicate how fee is determined:
❑ Standard City(Town Application Fez
2. Electrical $ ❑TotaLProlect Costa(Itgink xmultiplier` x
3. Plumbing $ 2. Other Fees: $
4 Mechanical (F VAC) $ Lis
t
5. Nechanical (Fire $ Total All Fees: $
Suppression)
Check No. Check Argount Cash Amount..
6. Total Project Cost: $5 �J 0 0 Paid in Full > ❑Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
,5.1 Constructionf Supervisor License(CSL) L
C! / �l Q WI " l° Q✓[ /�$ License um er Expnati
Name of CSL 1-[older
I5 (— ;L p�C List CSL Type(see below)
No. and Street ' - Type, - Description
13QU.goc , /6t 0/go U Unrestricted(Buildings up to 35,000 cu. f[.
R Restricted 18c2 Famil Dwzllin
Crty/Tos n State,ZIP NI Nlasonr
RC Rootin Coverin
C� Window and Si,-;-
-
SF Solid Fuel Burning Appliances
Q) Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
o 111420
/`/ r/
t-�1 )�1Q1N7 �BCQNOIl1 HIC Registration Number pira nDate
HIC Company Name or HIC R gistr nt Name
�merleefn Dviir4 e. We )
No. and St ce t
IS aa'jey A✓e 7R1 389 7I r7z Email address
Ci /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 TORE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
[, as Owner of the subject property, hereby authorize 4,Z 11/&/y/ J Q /aQ hq./g
to act on my behalf, in all matters relative to work authorized by this building permit application.
ke ; #ti 6/)1)eti r 41 O)&
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW 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.
h F/ 7i1 eyorJe tiNr ,c� b /3
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 not have access to the arbitration
program or guaranty fund under tNI.G.L. c. 142A. Other important information on the MC Program can be found at
www.rnass.gov/oca Information on the Construction Supervisor License can be found at www.mass <_,ov los
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 halt/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"