6 ELEANOR RD - BUILDING PERMIT APP ' Fhe Commonwealth of Massaclltl5CII5
Board of Building Regulations and Standards CITY OF
SALEM
Massachusetts State Building Code, 780 CMR Revi,sed.t/ur 201
L, o
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Duelling
This Section For lficial Use Only
Building Permit Number: Date Applied:
--moldingOfficial(Print N;une) Signalure Date
SECTION 1: SITE INFORMATION
1.1 Propert Address: 1.2 Assessors Map& Parcel Numbers
r L" ::O"L -
I.I a Is this an accepted street?yes no_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Prupowd Use Lot Area(sq It) Frontage Ill) -
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 ❑
Public❑ Private❑ Check ifyes❑ P P
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner' RecE
of ord:
OP/Y% � �C
Name(Print) / City,State,ZIP
7
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairsts)o Alteration(s) ❑ Addition ❑
Demolition - ❑ 1 Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': //ZiS'"7-/3[-C L, r ti� e-
Si�r�iZe,
/ �K T IJOOf�
SECTION 4: ESTIDIATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building S & 9atr .a I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S
❑Total Project Cost (Item 6)x multiplier. x
1. Plumbing S 2. Other Fees: $ ��� /
q. Mechanical OWAC) S List:
�. ,\IcehmticaI (Fire
Su iressionf S Total All Fees: S
Check No. _Check Amount: --- Cash :\mount:----
6. Total Project Cost: S /3, ;70, ` ❑ Paid in Full O Outstanding Balance Due:
cue ob
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(C'SL)
9�p�
License Numkn:r _-- Pspirulinn Datc
Nanrtn of CSl. Iluldcr �
List CSL'I')pe Isec bclutr) /Ll� - 0/s
No. and Street ,yJ -- Type Description
AoyvFitJ U l larestricted(Buildn%s ti to 35,000 cu. 11.)
C'it.w foon.Slate.ZIP R Restricted 1&2 Pumil Dwcllin+
M Masoar
RC Roolin,Covering
WS Window and Sidin
SF Solid Fucl Burning Appliances
IInsulation
l cic hone Email address D Demolition
5.2 �kee istered Home Improvement Contractor(HIC)
11
I IIC Coin Name or I IIC a'. tmnt Nant I IIC Iicgistration Number Expiration Date
Nuy�nd Street
//r9iy!/P/zl '0'e'p. %7, -77Y-03sf Email address
Ci /Town, State,ZIP Pele hone
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
I,as Owner of the subject property,hereby authorize h r /r
to act on my behalf,in all matters relative to work authorized by this building per it application.
Print Owner's Name(Electronic Signature) Date
FT ;do
ECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
ring my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and to the best of my knowledge and understanding.
tncr s or,\udutn zad Agent s Name Itronic Signature) __/ Dale
NOTES:
Owner who obtains a building permit to do his;her own work,or an owner who hires an unregistered contractor
t registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
gram or guaranty fund under M.G.L.c. 1 42A.Other important information on the HIC Program can be found at
_flla>s ;m LDS:) Information on the Construction Supervisor License can be found at2 2en substantial work is planned, provide the information below:
or area(sq. ft.) (including garage, finished basentent'attics,decks or porch)
ing area(sq. it.) Llabitable room countNumber of lircplaecs-_-----_-.--- Number of bedrooms
Number of bathrooms -- --------------
---------------_- Number of half baths
1}pc of heating system Number
---------- of decks)
pcofcoolhnesystem -
- ---------
. .---- - -._.------------- Enclosed O cn
3, "fol:d Project Square Footage"nmy be Substiuned Ibr"rood Project Cost" .