8 DEARBORN ST - BUILDING PERMIT APP a2 s,
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
O
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate O e olish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: a lied:
Building Official(Print Name) 1, Date
SECTION 1:SIT INFORMATION
1.1 Pr ddress: 1.2 Assessors Map&Parcel Numbers
I.1a 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(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.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owger'of Record:
VHiitLEy �F �ytZK J:�LEM WAL 67/y70
Name(Print) City,State,ZIP
7114-pSZ;2
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work : /e&wnet�Ec �Lcwv 11—ee& I?APr??y
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1. Building $ f�y� "` 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $
AZ ❑Total Project Cost'(item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
cv Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ��add Cl Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
Of Y E-7 License Number Expiration Date
Name of CSL Holder �.
�/9K�l EKL�1 D List CSL Type(see below)
3a J,Ez✓✓9 P c/T
No.and Street Type Description
Alp G11 fel U Unrestricted(Buildings up to 35,006 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
11,71r I 1
Insulation
Tele hone Email addre D Demolition
5.2 Registered Home Improvement Contractor(HIC) /6�a
�/lz<z4l�aa/ �E7yr.aO�Z/�/c� HIC Registration Number Expiration Date
HIC Iraom any Name or HIC Registrant Name
No.and Street Email address
/Ltf G/f4' i
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 BUILDING PERMIT
I,as Owner of the subject property,hereby authorize � ;e?~ Ar/f/w Mallob OY
to ad on my behalf,in all matters relative to workauthorized by this building permit application. /
5h(rIpy P//Ieuy
Print Owner's Narne(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 Authorized Agent's Name(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
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dis
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 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"
Contractor Agreement
THIS AGREEMENT made the 21 day of November,2011,by and between Shirley Lafleur
Hereafter called the Contractor and Precision Remodeling,hereinafter called the Owner
WITNESSETH that the Contractor and the Owner for the considerations named agree as follows:
Scope of Work
The Contractor shall furnish all materials and perform all of the work on the property at 8 Dearborn St Salem
MA 01970
Work Performed
Remodel second floor bathroom.
Contract Price
The Owner shall pay the contractor for material and labor to be performed under the sum of eleven thousand one
hundred sixty six dollars.
Progress Payments
Payments of Contract Price shall be made as follows a third down($3722.00)a third when structure is weather tight
and the remainder on completion.
Signed this day of ! /�,20
Owners / Contractor ;''