7 DEVEREAUX ST - BUILDING PERMIT APP JACKET LIE;
Z' 'rhe Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised,thir 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number. Date.A
�,. q ro
Sig afore- '. Date
( Building Official(Priat Name), bn
n SECTION 1:SITE INFORNIAT1014
1.1 Property Addres!� 1.2 Assessors Map&Parcel Numbers
` 1.[a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Properly Dimensions:
Zoning District Proposed Use Lot Area(sq tt) Frontage(Il)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yan1
Required Provided Required Provided Required Provided
1.6 Water Supply:(MAIL c.40,§34) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal(3 On site disposal system ❑
Public❑ Private❑ Check if es❑
SECTION2: PROPERTY OWNERSHIP!
2.1 0(Owner of Record:
)D �. CfZl�ti1J(�LL ��1 ewe M�} �l'XJ
k alme(Print) City,State,ZIP
r7 - e 97& 740-63�2 �av��• .er��r E� ,
No vad Street Telephone mail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ OwnerOccupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work`: Kewada I J Yr kt,- 4 — e-
SECTION 4: ESTIMATED CONSTRUCTION COSTS ti a
;n
Estimated Costs: Official Use Only ti m
Itoi° Labor and Materials) t7
I. Building Permit Fee:$ Indicate how fee is determi -'rn
I. Building $ 3-GGCs
❑Standard City/Town Application Fee O rn
2. Electrical S �j/(p GC7 ❑Total Project Costa(Item 6)x multiplier x -<
3. Plumbing $ ` OG "' V Qther Fees: $ o
4. NIcehanical (HVAC) S List:
5. Mechanical (Fire _ M
Suppression) $ "total All Fees:S rn
Check No._Check Amount: Cash Amount:
6. Tutai Project Cust: S $�� 13 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Dale
-
Name of CSL[folder
List CSL'fype(see below)
No.:md Street Type Description
U Unrestricted(Buildings tip-to 35,000 cu. tl.) !�
R ResUicted I&2 F:unil Dwellin
City/Town,State,ZIP M Masonry
RC Routing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No. and Street - Email address
Cit /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 CONTRACT 0RAPPLIES'FOR BUILDING.PERMIT
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Dale
SECTION 7b:OWNER!OR AUTHORIZED AGENT DECLARATION
By enter' g my name below,)hereby attest under the pains and penalties of perjury that all of the information
contai ed n this applicatio is ue accurate to t[lq best f t y knowledge and understanding.
WV
�\ Print Owner's or Authorize gent's Name(Electronic Si/iggnature) Dalk
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 naf have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at
www mass eov'oca Information on the Construction Supervisor License can be found at www�ns _
t 2. When substantial work is planned,provide the information below:
'total floor area(sq. R.) 'x ,(including garage, finished basementlattics,decks or porch)
Gross living area(sq. R.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
'fypeofcoolingsystem Enclosed- Open
1. `"total Project Square Footage"may be substituted for"total Project Cost"
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