5 DOWNING ST - BUILDING PERMIT APP JACKET Lto Z�sz
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards µµE;o SALEM
Massachusetts State Building Code,780 CMR ."IS PEG3 iQIY
(R2{-Mrgq011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling 201b JON
This Section For Official Use Only
Building Permit Number: plies'
U J Building Official(Print Name) Signature
I/ Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
j b✓+7i ✓✓
L I a Is this an accepted street?yes no Map Number Parcel Number
L— 1.3 Zoning Information: IA 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 IN to Supply: (M.G.L c.40,§54). 1.7 Flood Zone Information: 1.8 Sewage sposal System:
Zone: _ Outside Flood pone? Municipal On site disposal system ❑
Public Private❑ Check ifyesl�
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
J=r I E /IO/3'rJ1�� .f'gL¢rn A/!a•c�97o
Name(Print) City,State,ZIP
)641
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check a0 that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of ProposedWoW: J'T/LiP T E gh%//ZLr kabF 4"7G 4Z fn9lt UPi`7�
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
bor and Materials
1.Building $ 201 1. Building Permit Fee:$ Indicate how fee is.determined:
❑Standard City/Town Application Fee
2.Electrical $ r Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (RVAC) $ List:
5.Mechanical (Fire $ Total Ali Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 2 6�/, ❑Paid in Full ❑Outstanding Balance Due:
` I
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) YR2 9/
�M t' K PA 4ZCIV9� License Number E irapon ate
Name of CSL Holder
List CSL Type(see below)�
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 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
97�9zz z2y� I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement
oC�n/tractor(HIC) hp/slw�
?n HIC Registration N KpiAtion Date
HIC Corn any Name or HIC Registrant Name
7�/�a�vL .n7r ?/ 0351 Co
rlL.�.�a o�9�i 97t�-922 u.5y
� L
No Str t EU addz w
Ci /Town Telephone
State ZIP
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
to act on my behalt;in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) D to
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.
7
Print Owner's o orized Agent's (Electronic Signature) to
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.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dns
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"