16 E COLLINS ST - BUILDING INSPECTION JACKET \ The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Co 8l1 C R 7"edition OF SALEM
/ Revised Jammry
Building Permit Application To Con ct,Repair, en ate Or emolish a 1,2008
One-or Tw Family Dw
This Sq&ion For 9ft4oise qnfy
Building Permit Number::
Signature: 1
to ng ommissioner/ n crorof Build s - Date .
SECTIO :SITE INFORMATION
1.1 Ptpperty Addr e?s //,^ sr
1.2 Assessors Map&Parcel Numbers
L la IIss this an accepted street?yes_ no Map Number Parcel Number f
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) 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' ( ` -
'2�1 Ow r of eco�rd:d�L" �D F CO J /� /54 /-- Ca�
Nam ( . �1' Address Service:
9O 07/
Si ture Telephone
SECTION 3 DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition Cl
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of oposed Work': 1r6-114 Z ..Y
Andy C O M/
SECTION C ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee.$ Indicate.how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)xmultiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount Cash Amount:
6.Total Project Cost: $ 57('f 4L ❑Paid in Full ❑Outstanding
fBalance
eDDue:
`
Cc- a i �'C7 8Z 3 727 � a,cl��
!r SECTION 5 CONSTRUCTION SERVICES
5.1 Licensed Cons{ruction Supervisor(CSL)
J ,fib v _
�A/L -Cv�'nCl License Number Expiration Date
Name or�O CSL-Ho List CSL Type(see below).c ts,er
Address Type Description
U Unrestricted(up to 35,000 Co.Ft.
-- R Restricted 1&2 Family Dwelling
��zz M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliamm Installation
D Residential Demolition
5.2 Re -tgred Home Imp yv S��ement Contractor(HIC) /
HIC Cy pane y Name or III Regis lame A44
Re 'strati n Number
/U A10CF— /CAI��✓� t S e CEO�
ddress 6G _
Er itation Date
igo tore 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 -
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1-4 as Owner of the subject property hereby
authorize \1 t1 U( to act on my behalf,in all matters
relative to work authorized b this build;permit application.
9-
Signbt&e of Owner Date
SECTION_ 7bt`OWNER'OR AUTHORIZED AGENT DECLARATION
I,�1'.[��tG�'(-1 (� �( ��, PT ,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.
�Pne-r I n Sc y-
Prin /f`//
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of
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 110.116 and I IO.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 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"