65 DUNLAP ST - BUILDING PERMIT APP JACKET The Commonwealth of Massp�rpy�et ECE)VEC
° Board of Building Regulations an��`SStkkAMAL SERVICE$
Massachusetts State Building Cod 780CMR $ is,
Building Permit Application To Construct,Repair;We4KaZQ)rAeiH01i35a Revised
One-or Two-Family Dwelling August 15, 2013
This Section For Official Use Only
Building Permit Number: i Date Applied:
Signature: 4,7 7 �(//V
Building Commissioner/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Propert�Address: 1.2 Assessors Map&Parcel Numbers
51
L l a Is this an accepted street?yes Ve no Map Number Parcel Number
1.3 Zoning Information: 1.4 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 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'
2.1 Owner'of Record: J
Lcal' Gl�/�� �' �yti�
Wntl. Address for Service:
q-7 Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 Existing Building Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number ol'Units S Other ❑ Specify:
Brief Description of Proposed Work':
.S/G(. CPjGif 1164,11 u
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: i Official Use Only
Labor and Materials i
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined: '
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ 0 r
4.Mechanical (HVAC) $ List: v_
5.Mechanical (Fire
Suppression)
$ Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ Y/�Lr 3 0 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES c
5.1 Licensed Construction Sup_erijio'rJ(CSL) d LZ`f-57
/Ct CW412q License Number Expir io Date
Name�C8 Hol, �er _ t r� •'1
en�VY�^� List CSL Type(see below)
Address Type Description
U Unrestricted(up to 35,000 Cu.Ft.)
R Restricted 1&2 FamilyDwelling
Signature�+,�F y,.3 y 71 M MasonryOnly
// RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) 111G 1 7
HIC CompJ�anYY Name or HIC R�e�i.st5ant Name Registration Number
.�tYd".S fNfr.�9nY'IU��Li�—rtG
Ad ss
T7(-7 E pira on Date
Signature Telephone
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
OWNEW S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 64 t M'' 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.
6 c✓ (,� �/,?-, y
Si ature of Owner Date
SECTION 7b: OWNERt OR AUTHORIZED AGENT DECLARATION
I, lx�" ,as Owner or Authorized Agent hereby declare
that the states ents and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf
Print Nam(/VC 71��4z/c/
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 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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 halfibaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
Try- � u - i � � z
%79 $LtJ
The Commonwealth of Massachusetts S RV ICES
q� Board of Building Regulations and Stand at-SPECT10NAl CITY OF
Massachusetts State Building Code, 780 CMR LEM
pp ��((�� ,�'vr Mar 2011
(� Building Permit Application To Construct,Repair, RenovatexD 001i'shh a
One-or Two-Family Dwelling
This Section For Official Use Only
1 Building Permit Number: Date Ap lied:
ilik >M l/ (�
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Prope Address: (C�� 1.2 Assessors Map&Parcel Numbers
�o � la_p J74-
L 1 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 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSIHP'
2.1 Owner'of ord:
Cam,-,• L N,•
Name(Print) � City,State,ZIP
G� IV-t-+.n/a.10 Yi-.
No.and Street I Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WOW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other Specify: O
Brief Description o Propo,*d orl;:
ri!- ce iN f�ti
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 6 rfljs 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Q Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 9qs ❑Paid in Full ❑Outstanding Balance Due:
mPA4=D lV119 Tb rnRC'5 (SFa-T-ti_
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 2 7 / 7 77 q 3 /6,
License Number / Expiration Date
Name of CSL Holder U
Eric W. Palm . List CSL Type(see below)
No.and Street 3 11iWn street Type Description
Salem MA 01970 U Unrestricted(Buildings u 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
[ IInsulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 1 0 9 G g z, /&
Atlantic Weatherization,LLC HIC Registration Number Expiration Date
HIC Company Name6Q,fR418 4%WUe
No.and Street MA 01070 Email address
City/Town,State,ZIP Telephone
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 IssuaricuPhe 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_ Fr r C. ea //, 1
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name i�ge ure 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 this application i V d accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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.gov/dys
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"
I= tVo��
What A the current use of the Building/t it dwelling•how many unft?--------
Material of BuiidbV? Asbestos?
"a the Building Co�to Law?
_ L/O /c
Archileas Aadrau ptwne `L.lUlgPVaN(Z �? h
Mechanies Name
Addrags and Phone HIC Registration 0
Construction Supwvvism License 0
EstLnated Cost of Proled: 0' GG' PermR FN Ca migdon
Estimated Cost X$?/$1000 Residential
Permit Fee i EsW ated Coat X S11/i1000 Camnarcial
�07 G An Additional $5.00 is added as an
Adminial advO charge.
Make sure that all fields are Property and iegrbly written to avoid delays in processing.
The undersigned does hereby apply for a Building P to build to the above sta
specirications. Signed under penalty of perjury
Date O
i
N
O
L v
x
i.
CrrrOF
PUBLICTPopERTY
DEPARTjvj& iT
MAVM
1OWwAyu7+cSR1N J�IIFJrr•imak-M&gL M3k1-s 01970
lb-.9. 7iS.9M•FAM 97e•740.gM
O RE RE N ONSTRUCTIO N
DAPPLICATIONF R TEE PAIR. OVATrO C
EyaOi.iiiOi�I — c:.tiArr-- O R
OR
Ox GE F US O OC mANCY F ANY EXISTING
STRUCTM OR HUILDnV�
1.0 SITE INFORMATION
Location Name:
9wldtnq:
Prop"Addreaw— — - - -- -
�
Property is located in a:Conservation A-m- WN Hlsstorlo 010M YM
P2.8OWNERSHIPINFORMATIONMATION S• � P%9- - SW-
3-0 COMPLETE THIS SECTION FOR WORK IN E]r1ATtun BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition
Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
Mail Permit to: -- -
i