69 DEARBORN ST - BUILDING PERMIT APP (002) The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY SALEM
Massachusetts State Building Code, 780 CMR dMar
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
I1oJ One-or Two-Family Dwelling t
This Section For Official Use Only
Building Permit Number: Date Appli
� rz
Building Official(Print Name) ignatme Date
SECTION 1: SITEJNFORMA3n
1.IJ rMAddress: I.A&S s MJV&Parcel Numbers
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(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Wa upply: (M.G.L c.40,§54) 1.7 Flood o ormation: 1.8 Sewage Disposal System:
P861CJ L Private❑ Zone: _ Outside od Zone? Municipal XLOn site disposal system ❑
Check if yes
SECTION 2: PROPERTY OW RSHIP
2.1 Owner'of Record:
Name(Print) City,State,ZIP
6a D ri c _5+- �7 2V111 7
No.and Street Te one Email Address
SECTION 3:DESCRH'TI OPOSED WORIO(check all that apply)
ew onm etiea4; g uilding❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work 2: ' r,L ,v wA U L,�J' ( �; V
- T
a
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ -2 _ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $/l 0 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
n CS—OI-30�}.� J � �O!
ik-nF _ l/ 16���/ License Number xpira on Date
Name of CSL Holder
List CSL Type(see below)
&(n le kkapea -9+.
o and Street Type Description
�
y� ,q U Unrestricted(Buildings u to 35,000 cu.ft.
/WA 191170 R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
j]�3'9Yy o2(l��G° SF Solid Fuel Burning Appliances
�1�7�1�l��J9 slJ.�/�fJ/1�9�'�US �/�df� �D I Insulation
Telephone Em I address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
.• r� /l�logU� 7
si /"mz hanks �. -Y HIC Registration Number iration Date
C Co n Name HI Registrant Name
No.and Street mail address
AYld 4W,20 97v 7t/�%/5 9
Ci /To 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
,c7
1,as Owner of the subject property,hereby authorize �iL (/ 6�l�ii�
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(El ironic Signa 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..di
Print Owner's or Authorized Agent's Name(Electronic Signature) T 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/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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"
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