13 DUNLAP - BUILDING PERMIT APP JACKET The Commonwealth of Massachusetts FOR
Board of Building Regulations and Standards MUNICIPALITY
1
Massachusetts State Building Code, 780 CMIt, T".ed-ition USE
Building Permit Application To Construc epair, enovate Or Demoli a Revised January
�Y W 1, 2008
One-or Two-F ily Dwel '
a This Sectio For Offi ' I U e ly
Building Permit Number: Dat ppl'
Signature:
Building Commissioner/Inspector ofBuildmgs Date
SECTION 1: SIT NFORMATION
1.1 Prop e A.dess: I ^ 1.2 Assessors Map&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-tilse '. 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 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system El
Public❑ Private❑ Check ifyes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record•
rJ V-a54—
/
Name(Print) Address for Service:
-7 �
r — 3
gnamre Si Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteeation(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Pro posed Work': ff; �' Ce.� — W�-�' C
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
1.Building $ 1. Building Permit Fee:$ -Indicate how fee is determined:
❑Standard City/Pown Application Fee
2.Electrical $ ❑Total Project Cost"(Item 6)x multiplier x�
3.Plumbing $ 2. Other Fees: $
4:Mechanical (HVAC) $ List:
5. Mechanical (Fire - $ Total All Fees:$
Suppression)
Check No. Check Amount:77—Cash Amount: y
6.Total Project Cost: 1 7706,"0 [1 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) (P79 ) .1 .7 3
�y 1 License Number Expiration Date
Name of CSL-Holder 3 fltIt&� t _q List CSL Type(see below) 4
Address Salem MAIM070 Type - Description
U Unrestricted(up to 35.000 Cu.Ft.
Signature w /J
R Restricted 1&2 Family Dwelling
M Masonry Only
RC Residential Roofing Covering
Telephone�q r' WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
/ Hao71/
HIC Company e _ Registration Number
tc 1 t I_fbM"•+ >•Yuu�4 a. P 3 Address
_ Salem MA01970 'I7C T(J-?IY3 Expiration Date
Signature Telephone -
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. g 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 Issuanc of the building permit.
Signed Affidavit Attached? Yes .......... ef, No._........ ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, bkeJ k/ I �5 e— as Owner of the subject property hereby
.authorize C /,, --. (-k I>—I to act on my behalf,in all matters
relative to work authorized by this building permit application.
2—
Si nature of O er - .Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I,_ �L �u-✓ ,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 Name
Signature of Owner or Authorized Agent Date -
(Signed under the pains and penalties of perjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I I O.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage;finished baserii'enUattics, 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"