3D DEWEY DR - BUILDING INSPECTION (3) JACKET The Commonwealth of Massachusetts
y hoard of Building Regulations and Standards Pc lit
1 t. Massachusetts State Building Code. 780 CMR. 7 edition USE
Building Permit Application To Construct. Repair. IZenaxa[e Or Demolish a K,riwJ.huuwu,% I
One- or Two-Funtih Dnellinq 1. 'nns
This Section For Official Use Only
Building Permit umber: Date Applied:
7A9
ed I ypectur of Buildings Dam
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map & Parcel Numbers
on
Ma Nunihcr Purrcl \'umber
1.1a Is this all accented,sveerl yes_ no_ I
1.3 Zoning Information: — j :.4 P:'aperly Jf^tenseors:
Zoning District Proposed Use Lot Area(sq f) Frontage i It)
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. d0, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone:' Municipal ❑ On site disposal s acm ❑
Public❑ Private[I Check if yes❑ P I y
SECTION 2: PROPERTY OWNERSHIP' _
2.1 Owner of Record:
��i4 Y (/ �/ ✓1/ LL A Tl l Y 3— D flP
Nance tPri it) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ specify: l
Brie'Descriptio�nt�of P�rcposed Work'':
Ceu
SECTION 4: ESTIMATED CONSTRUCTION COSTS —�
Item Estimated Costs: Official Use Only
_ (Labor and Materials)
I. Building $ J �'h 1. Building Permit Fee: $ Indicate how fee is determined:
/ �y� ❑Standard City/Town Application Fee
2. Electrical $ (O!/V ❑Total Project Cost' (Item 6) x multiplier x
3. Plumbing g $
G(/ . ./'9 3. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ j
Suppression) Total All Fees: $
�!, t Check No. Check r\mount: Cash AmounC _
b. Total Project Cost: $ V �O ❑ Paid in Full ❑ Outsttaanndin/g Balance Due:__.—_-_ ��1
r2ode%as�, Aw
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) \ 3 O"D,a-6
t C 0 lqr p J /1 q D/S 6.4/ License Number Expiration Date
Name of CSl_- Ilulder
List CSL'fypc(see below)
!— "fype Dcscri oon
\dd
C Unrestncied(Lipto 15"(00 Cu. PI.r
R Restricted I:r'_ Fanuh Duelling
Signature / M Masonr\ Onlv
y Ut �3` _� �`� RC Residential Rooting Comic
'felephune \\'S Residential Wlndum and Siding
SF Residential Sohd Fuel Bunung \ t th:mcc I15L111.lnnll
D Residential Demuliuon
5.2 Registered home Improvement Contractor (HIC) --
HIC Company N x ur HIC egistrant Name Registration Number
"j Ai 140lSGf4 L �i/'U(/J= �/� �_ �_✓_S C Expiration Date
Signatu Telephone [,6e.'�43 r
SE N 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
L�A fn}//y (��} �L-. /�� /% as Owner of the subject property hereby
authorize —to act on my behalf, in all maners
relativ t work authorized by thi building, permit apolication.
SI nag anne UI Ou9 r :�L-4 Z��, ._. Date _yI
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
i, C /1-112 as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Nam` AlRolf J.rO/\
(jI l-j rU J / 3 : a te L
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of er u )
NOTES:
I. An Owner who obtains a building permit to do his/her own work, or an o.vrer who hires an unregistered contractor
(not registered in the Home Improvement Contractor (HIC) Program), will not h-.ve access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program Lind
Construction Supervisor Licensing (CSL)can be found in 780 CMR Regulations 110.R6 and I IQ.R5, respectively.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.I _ (including garage, finished basement/auics, decks or porch)
Gross living area iSq. Ft.) Habitable room count _
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/bnlhs
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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OPL11N61MMIDE fILfB4ID APPR®VEo BY THE
J kMPECMQB PRW TO A PERMIT BEING GRANTkD
CITY OF SALEM -
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Permit to: BUILDMG PERMIT APPLICATION FOR:
(Clyde whichever apply) Roof. Romd. Instal Siding, Ca*n& peck. Shed, pooi,
RepaidRepka. Other:
PLEASE FILL OUT LEGIBLY Ik COMPLETELY TO AVOID DELAYS M PROCEsgMO
TO THE INSPECTOR OF BUILDINGS. '
The undersilpred hereby aPPHss for a Permit to build accor&g.to the.W&*Ing
spedficatiorrs:
Owner's Name ,S//A Rr,./ U pI LL.P4-
�rck��
Address a Phone 3 C) Q
Archileat's Name
Address & Phone ( I
Mechanics Name F- U w��.� �Qo S
Address3Phone %Q CoC-CofqA
wn.r a n.a•ao••a tu�alns'+ S er�l l� ,C.�. ,..,_�'�, C�r--�f G
NIrMW a buldr� w o �P K a dwOM,ror now many h din?
WE bddho ootionn to low? y f-r Aob@W=?
Ewmu@d=Gt O Cy tJo WA*uomw• O`(O 3
tisti
C�'' .
S re of
UNDER THE PENALTY'
DESCRIPTION OF WORK TO BE DONE oR PERuuRY
12fz � �P cl,sC-�
MAIL PERMIT
.t.
APPLICATION FOR
PEFEW TO
ga lw
LOCATION
PERMIT GRANTED
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AP VfD
INSPECTORVF BUILDINGS
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