42 DOW ST - BUILDING INSPECTION i t
( Fhe Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
n a i Massachusetts State Building Code, 780 CMR
lZerisod.1/ur 2011
y
Building Permit Application To Construct, Repair. Renovate Or Demolish a
One-or Two-Famili, Dwelling
This Section For Official Use Onl
Building Permit Number: Date.Applied:
Building Official(Print Name) Signature Dat
SECTION I: SITE INFORMATION
Property Address: 1.2 Assessors Map& Parcel Numbers
I'Ia 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 It) Frontage(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.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION2: PROPERTY OW SHI t
2.1 er of Recor
/ r�rzlwt td:%NOROC 5)ou� S,�Zr,M 019'�
N;mte(Print) City,State,ZIP !,
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ ther ❑ Specify:
Brief Description of Proposed Work': 'RGet-AcgY14[NI01� INSY-Zw 1o0 HGr-Tteocuf o C;
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.St'1C1=T V2ncK oW S LcnDVL E uzoorvi vcTr a9 t 2C 4tvteCry stir 6 t�
ZD)S cLRTro / ZtGC? Ooclu OA) TH1Vz0 260VF C 12U0✓2
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Mmerials)
1. Building S �)pp_DO I. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
'_. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $
4. Mechanical Ili\':\C1 S List:
t, \lechanical (Fire S Total All Fees: S
/ Su t lrcssionl Cheek No. Cheek:\mount: Cash :\nwunt
----
6. Total Project Cost: S ll. a60 00 ❑ Paid in Full ❑Outstanding Balance Due:
(all
Cact
SF.('TION 5: CONSTRUCTION SERVICES
5.1 Construction
Supervisor License(C'SL) Sys, �. , 7, —
u G I-q \'-` _ Lieensc Nwn—I+cr Ifcpira 1
CQ-
Name ol C'SI. I lnlder
�S uj S l List CSL T)pe(see below)
No. :mJ Strcct tt I.Vpe Description
0,21 9 U Unrestricted(Buildings ti l0 35,000 cu. 11.)
C'ilylfown.Slate,ZIP R Restricted L$? 1'mnil Dwelling
M Mason
RC Roofin,C'owrin
W:S Window and Si&-
�7�33! SF Solid Fuel Burning Appliances
� ��I3/✓SZ IPVICC!'6,YAHOD- I Insulation
"I'cic bane limail address v� U Demolition
5.2 RegisteredHome Improvement Contractor(HIC)
I IIC Company Name or I IIC Registrant Name I fIC Registration Number lispiralion Dole
No.and Street
Hmail aJJrcss
City/Town, State,ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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
to act on my behalf,in all matters relative to work authorized by this building permit application.
Not Owner's Name(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 application is true and accurate to the best of my knowledge and understanding.
®fo`�D
sner's or Authorized Agent's Name(lilecuorue Signature) Dale
NOTES:
I. 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 riot have access to the arbitration
program or guaranty fund under AI.G.L. c. 142A.Other important information on the HIC Program can be found at
i❑0,2 t;ov oc7 Information on the Construction Supervisor License can be found at t%w_a_.nia;s you SIPS
'_ When substantial work is planned, provide the intormation below:
Total fluor area(sq. fl.) _(including garage=count
sement'attics,decks or porch)
Gross living area(sq. It.) Habitount _`'umber of freplaces _ Numboms----
Number of bathrooms ---- -----------
Numbaths1)pe of heating system-- Numb porches----.----- ------F)pe ofcooling Sr Stem --------- InclosOpen7 "fatal Project Square Footage-ntay be substituted fitr Total Project Cost'• ----- ------ ----