49 DUNLAP ST - BUILDING PERMIT APP JACKET The Commonwealth of Massachusetts
1 a� CITY OF
UBoard of Building Regulations and Standards SALEM
?�C Massachusetts State Building Code, 780 CMR Revised afar 2011
Inc
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use O y
Building Permit Number: Date Ap - `
C
Building Official(Print Name) Signature Date
SE ION 1:SITE INFORMATION
l.l. If�pectAd ress: 15f 1.2 Assessors Map& Parcel Numbers
1.l a 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❑
^ / SECTION 2: PROPERTY OWNERSHIP'
v 2.1.Owner' Record:) Gf
Name(Print) City,State,ZIP
`�q �ya,t� S� 773 `b76- o)Sqq
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(sa I Alteration(s Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other X . pecify:
V Brief Description of Propo d W r`k � Cu J
S twix& Lo7''' tv 129vl V LVti "t oC t
t
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials) -
I. Building $ 5 000. 00 1. Building Permit Fee:$ Indicate how fee is determined:
'. Electrical $ ❑Standard City/Town Application Fee
❑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: Cash Amount:
`r 6.Total Project Cast: S s_oOQ _� 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.I Construction Supervisor
�License(CSL) gC111
aJ � G p�
e4 {��lill� License Number EXPIation ate
Nantcof CSL Bolder �S
List CSL'fype(sce below)
No.and Street Type Descrip on
dim A2 U Unrestricted(Buildings u' to 35,000 Co. 11.)
F't%RJ�ro �t 11 U Y J R I Restricted 1&3 Fainily Dwelling
CityfI'own.State,ZIP M Mason
ty
RC Roofin Coverin
WS Window and Siding
��D ,ip SF Solid Fuel Burning Appliances
- 7 /l( �(/( Insulation
Tcic hone Finai address D Demolition
5.2 RegistereA lloae mprovement Contractor(HIC) ' ��U %� 21 1
V& KA, I IIC RegistrationNumber E pir t1. m Uatc
FIIC i an Name or IIC Itegistr t Name
i
IV). 8 Street 0 r) l � 78 2 /_ / _ Email a ss
City/Town. State,71P OTcJICDhho(ne /
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 A THORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR
,APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize r'�'�+ �Jl LLA—J1L
to act on my behalf,in all matters relative to work authorized by this building permit application.
�L°V1rl t�''Vl �•�2��t<t �q (O fo I I
Print Owner's Name(Electronic Signature) I Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby atteVue
p i s and penalties of perjury that all of the information
contained in this application is true and ach t of my knowledge and understanding.
fl ww N e Ito 1
Print Owner's or Authorized Agent's Name(EI onic:igna vre) to
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 not 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
Information on the Construction Supervisor License can be found at w��tv.nrnaau_41ps
2. When substantial work is planned, provide the information below:
Total fluor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. It.) Habitable room count _
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfrbalhs
Type of heating system Number of decks/porches
Type of cooling systent _ __ Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"