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16 DEARBORN LN - BUILDING PERMIT APP The Commonwealth of Massachusetts f Board of Building Regulations arid Standards CITY OF SALEM Massachusetts State Building Code,78 CMR,7"edition RevvisedJanuary JJJ Building Permit Application TqConstruct,Rep r,Renovate Or Demolish a 1, 2008 One-or T o-Family elling tlli Se 4"11Tpt . ':' bnty 13triytling PennitNumYter: ; " ' �ate'Altplt�d ,.Signature �� Bmldiiig omthtasiener71pSP4ct. f d �. ' � ` "'-data , 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers �6 11r�MeI7 1, iI r " 1.1 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(sgft) - Frontage(ft) 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: Outside Flood Zone? Zone: _ Municipal❑ .On site disposal system ❑ - Public❑ Private❑ Check if yes❑ II ;; , ° ;ECT)ON Z;%P!RO�� i"Sd�O1TSHj1+•' 2.1 7n r'of Itecor L U `t_,_. �V /✓C'�/� �J U� /1 L k// �' �(P ,[Name(Print) Address forService: Signature Telephone aW0" x ckeck all-that New SECT1l1N3 DECRIPjI01�llgQOSE1 Construction❑ Existing Building❑ Owner Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work : SECTION 4. ES fl<151ATEj1:CONSTRUCTION COS S Estimated Costs pfftera Luse Item Labor and Materials 1 Budduig Permit l ee $ Indicate how fee is determined: 1.Building $ 7iSt ifd6bi Cit it Appl3eation.Pee 2.Electrical $ �Total pro e :Cost' em ) rh41t}plier x 3.Plumbing $ � @sk r — 4.Mechanical (HVAC) $ Zt r 5.Mechanical (Fire $ �TotalAltles, � Suppcession) r, speck Amount: Cash Amount: 6.Total Project Cost: $ / J U p Pmd tml ull [?.Outstanding Balance Due: SECTI N 5 Ki¢N�S1}RCi�IOV 3EItX YCS_ 5.1 Licensed Construction Supervisor(CSL) Mi , If L — License Number Expiration Date Name of CSL-Holder _ List CSL Type(see below) y r!Dbsari"lion - - Address ,� f) U Unrestricted(up a Sly U Cu.Ft. � R Restricted t&2 Family Dwellin Signature - /� M Maso Onl Gl-��i-�7 �Z S �j 3 RC - Residential Roofing Covering Telephone WS. Residential Window and Siding SF Residential Solid Fuel Burning A liance Insmllation D Residential Demolition 5.2 Re istere H_ e I tprovement ContraGtorLIC) fd 5 LL Registration Number HIC CoppB°,;Name orn C Re rt e AddreSGA lX.�.r�s� I (;^ Expiration Date Signature ` /A� Telephone SECTION 6 WORKERS'COMPENS>TiON INSURANCE AFF3DAVIT(M G. x. 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 7aO1.1EII AUK H©RZA1IO111 G BE3C YZ ° 1 WHEN 1 OW1!FER'S•AGENT.ORsCON>RACTbR'i1PPEISSFUR UT1�INPERMIT I ��v�• � /gyp '-C " as Owner of the subject property hereby to act on my behalf,in all matters authorize relative to work authorized by this building permit application. Siaature of Owner Date �'; SECTION�7bOWN�SRxO LR 11',�•)�,Oii)7r„�Dy1;��N3'�I1E�LARAT,3ON' , ' : as Owner or Authorized Agent hereby declare that the statements�—and—informatiot on the forego mg application are true and accurate,to the best of my knowledge and behalf. Print Name '�^ J�„ o- Al Signature of Owner or Authorized Agent Date (Signed under the pains and enalties of er u - 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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.R5,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"