2 EMERALD AVE - BUILDING JACKET I O Z C* l 2RE
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The Commonwealth of Massachusetts �C TY OF S
Board of Building Regulations and Standards SALEM
?' QGTlO �� TY OF
Massachusetts State Building Code,780 CMR pp t �
Building Permit Application To Construct,Repair,Renovate Or DeAbishHaY I w r
One or Two-Family Dwelling I. 1 1`I
This Section For Official Use Only.
Building Permit Number: ' Datepied:
t
Building Official(Print Name) " -7 Signature " `, - Date
SECTIONI:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes "y no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq fl) Frontage(R)
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 yesO
SECTION 2i PROPERTY OWNERSHIP'
2.1 OwnertoTReco d:
Name(Print) City,State,ZIP
d &MO AL13
No.and Street Telephone " Email Address -
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check ail that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) lk I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work :
7 11 G�to& tS r'7cv0 hJ
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official U Only,
abor and Materials
1.Building $ 26 o0e) 1. Building Permit Fee:$ Indicate how fee is determined'.
2.Electrical $ ❑Standard, City/Town Application,Fee
❑Total Project Cost'(Item 6)z multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ _ List:
5.Mechanical (Five $
Su ression Total All Fees:$, "
r Check No: Check Amount:, Cash Amount:
6.Total Project Cost: $ 2�-6 0o p ❑Paid in Full ❑,Outstanding Balance Due:
IV1�tLa:p 's
SECTION5: CONSTRUCTION SERVICES
5.1 Construction'Supervisor License(CSL) CS
License Number xpiration Date
Narne o CSL'Holdei 7{. 37'
4_ hlp� - List CSL Type(see below) U
No.and Street Discriptidn
„ _ I � - U (Buildings amp el u to 35,000 cu.ft.
�(}�(_/� � R Restricted Family D
Ciy frown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
lJ?(es Z� I Insulation
Tele hone Email address D Demolition
5.kRregri-ste'retd Home Improvement Contractor(HIC) �, a _L�
I = l/FK1.JhJk;t ]I.c(S HI Registration Number Expir" auon Date
HIC Company Name or HIC Registrant Name
yc- Fi=,MnL b+3
No.and Street Email address
430.for K'-2C4c(( ct..•la eLF3z ?�2L.l�7aQ—
Ci /Town,State,ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NLG.I.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 ......PIP, No...........❑
SECTION jai OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTgR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize A Lk �LCA/47t S
to act on my behalf,in all matters relative to work authorized by this building permit application.
II
t��Y�AJU Cc V PLt°f 5
Print Owner's Name(Electronic Signature) Daze
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 is true and accurate to the best of my knowledge and understanding.
tc,
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
xww.mass. ofl v'oca Information on the Construction Supervisor License can be found at wL w.nrass _ov/des/des
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"
4
1 The Commonwealth of Massachusetts
Board of Building Regulations and Standala� RECEIVED CITY OF
Massachusetts State Building Code,780 Ctv`h2PECTIONAL SE VPG SiLEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renova rt
One-or Two-Family Dwelling !° g` b b
This Section For Of ow Use Only
( Building Permit Number_ Date p]iedi
Bmlding'Official ftnt Name) Signature-
^n ,SECTION I,SITE INFORMATION '
1.1 Proper Emef�i �� �� SAktm 1.2 Assessors Map&Parcel Numbers
L 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 11) Frontage(fl)
1.5 Building Setbacks(it)
From 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 OwnerrofRecor M (7l
`andf' j�0 V-1 1 Sara m
Name(Print) City,State,ZIP
a i-Mef<I d A-L-2 13�5� �iricL\Cu�¢ �JCosvlt�S • T
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work=: u l i O
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: O1Seial Use Only
(Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate flow fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier is
3.Plumbing $ 2. Other Fees: $
( 4.Mechanical (HVAC) $ List:
1
5.Mechanical (Five Suppression)
$ Total All Fees:$
_ Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ g 0pc7 ❑Paid in Full ❑Outstanding Balance Due:
M rvt U Ee�o ' D 1A. c!) . S 2s
SECTION5: CONSTRUCTION SERVICES �
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
to t Y g P 1 Y t l .•a; List CSL Type(see below)
No.and Street Type Description.
U I Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwellin
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS window and Siding
SF Solid Fuel Burning Appliances
I I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State,ZIP Telephone
SECTION 6:WORI{ERS'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 AOENT OR CONTRACTOR APPLIES FOR BUMPING PERMIT
I,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.
Print Owner's Name(Electronic Signature) 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 is true and accurate to the best of my knowledge and understanding.
11 1®A C itl/ic7 cz -'-fits_'
4Pfmt-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
wtivw.mass. oa v,'oca Information on the Construction Supervisor License can be found at www.mass.eov/dns
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"