11 EDEN ST - BUILDING JACKET The Commonwealth of Massachusetts FOR
e Board of Building Regulations and Standards MUNICIPALITY
Massachusetts State Building Code,780 CMR,7"edlGpin i.�, �- USE
j Building Permit Application To Construct,Repair,Renovate Or Depltlirshia Rev sed January
r One-or Two-Family Dwelling I, 2008
�1 This Section For Official Use Only
Building Permit Number: �' Date Applied:
3p � 3
Signature: - -
BuildingCommissioner/ orof ildmgs Daze
S ITE INFORMATION '
1.1 Prop?Ad�r �-� 1.2 Assessors.Map&Pa`cgl tlVfgmJ�ersF��l,;,I:_
!' dd e./1
L1 a Is this an accepted street?yes_ no_ Map Number '` ParcetNumber
13 Zoning Information: IA Property Dimensions:
- Zoning D.,Mct Proposed Use =Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks( -
Frout Yard Side Yards Rear Yard
Required Provided Requhed Provided Regduued 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 ❑
Public❑ Private❑ Check ifyes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owuer rR e /(/ /�-
5 � cruel
Name(Print) Address for Service:
7 Y5_93
Signature Telephone `
SECTION 3:DESCRIPTION OF PROPOSED WORK"(check aB that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ NumberofUnits_ Other ❑ Specify:
Brief Description of Proposed Work": n; 5Uti H
Fo
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only -
Labor and Materials
1.Building - $ - 1-. Building Permit Fee:$ Indicate how fee is determined: -
❑Standard City/rown 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)
ti Check No. Check Amount: Cash Amount-.
6.Total Project Cost: $ 906G.da 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES ..
5.1 Licensed Construction Supervisor(CSL) bL3 /y
License Number l Expiration
Date
Name of CSL-Holder �ji List CSL Type(see below)
3,ffikD*St=t
Address SMem MA 01 WO Type Description
U Unrestricted(up to 35,000 Co-FL
R Restricted M FamilyDwelling "*
Signature M Masoury Only
RC Residential Roofing Covering
Telephone - WS .Residential Window and Siding
SF "Residential Solid Fuel Burning Appliance Installation
D Residential Demolmoa
5.2 Registered Home Improvement Contractor(IHC) 'i,-)0 n
HIC Companl Registration Number
hi R lefF' O A�=u
Address Salem MA 01970 Q aL7`1 y- f`(� Exp' tion ate -
gd
Telephone i -
ION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
mpensation Insurance affidavit must be completed and submitted with this application. Failure to providet will result in the denial of the Issuance of the building permit.
avit Attached? Yes .......... No...........O7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize .A, 4�_ to act on my behalf,in all matters
relative to work authorized by this buildingpermit application. - - -
�o.).'
Signature of Owner Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
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
Signature ofO.vneror 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 underM.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 OR6 and I I O.R5,revectively. -
2. When substantial work-is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basementlattics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms -
Number of bathrooms Number ofhalf/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" -