76 ENDICOTT ST - BUILDING JACKET The Commonwealth of "4 CITY OF
r SALEM
Board of Built
1VM de ISO=
Massachusetts late M. M B;� -of co I Revised Mar 2011
Building Permit Application To C I "! J�tcovge ORDernolish a
One-or T=Xtqe I
1,1 Property Address: L2 Assessors Map&Parcel Numbers
& ENDIUJT ST. UN IT 2.5_6 q.5 go I
Lia Is this an accepted street?Yes— no Map Number Parcel Number
1.3 Zoning Information: IA Prop"Dimensions:
Zoning—District Proposed Use Lot Area(sq ft) Frontage(ft)
1.$ 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:
Pbh,Er' Private 13 zona Outside Flood Zone? Municipal&bn site disposal system 0
Check if yesO
... .. ...
2.1 Ownerxof Record:
:5aoE9r-_c_r, , r. 5AL-cm A4A QN-70 -3057-
Name(Print) City,Stew,21P
_14�) F_*1D'e-cnTT Sr q2_8-14 P4-- /0-76
No.and Street Telephone Email Address
_DFSCR _M
ap,
New Construction 0 Mdstmg Building 13 Owner-Occupiod 0 Repairs(s) o Alteration(s) Addition 0
Demolition 0 Accessory Bldg E3 Number of Units I Other 0 Specify:
Brief Description of Proposed Wo&'- 'Ke-Mbde-1 exestinq 2- - Rie-ce 13ci.--H1
t2 lccste
Esfimated Costs. Eholy
Item
(lAbor and Materials
)
1.Budding $ zi boo
2.Electrical $ 600 PA
..........
UP
3.Plumbing $ q.000
4.Mechanical WAQ $
5.Mechanical (Fire
S ression
CbeckATo 6.Total Project Cost: $ .......
5.1 Construcfwn Supervisor Lkense(CSL) LicenseNumber -fx—pvation Date
Name of CSL Holder List CSL Type(see below)
No.and Street
U Unrestricted(Buildings up to 35,000 Co.It.
R Restricted l&2 Family Dw
Cityfrown,State,ZIP M Masomy
RC
ws— Window and S*
SF Solid Fuel Burning Appliances
Insulation
Demolition
Tel bone Email address D I tF
5.2 Registered Rome Improvement COiatrocWr(R'Q 15954(
PR L- SfrOJIV CAP-Pf-44-i P-V_ HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
pr%te-
No- =I-mail ac@resi-
1-,1 1,1 , 1,k A. 6 4
-ji-ty/Town,State,ZIP '--Tcl 2pbom-1-
Workers Compensation Insurance affdwd must be completed and submitted with this WPIW,41:101L Failure to Provide
this;affidavit will result in the denial of the Issuance of the building Permit -Z�--
rr 6
Signed Affidavit Attached? Yes..........E3 No-.......... f
L as Owner of the subject property,hereby authorize
application
to act on my behA in all matters relative to work authorized by this building Permit aPP
Print es Name(Electronic:Sigaabare) Date
By entering my name below,I hereby West Under the Pam and Penalties Of perjury that all of the information
contained in this application is me and me mate to the best of my knowledge and understanding.
b 7-/
<Print eYa Authorized Date
1. An Owner who obtains a building permit to do WsRicr own work,or an owner who hires an unregistered contractor
(not registered in the Rome huprovement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under NCG-L.C.142A.Olber important information on the HIC Program can be found at
www.mass,my/ocalnformafiononftConsUwdmSBPcrvis"LkensecaubefOundatMm -mass�ov/ds
2. When substantial work is plam'Dd,Pmvift the infOrm3fionbeb": . fi basement4attics,docks or porch)
Total floor area(sq.ft.) (including garage,
Gross living area(sq.ft.) Habitable mom count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of haff/ballis
Type of heating system Number of decks/porches
Type of cooling system— Ewlosed_Open—
i3. "Total project Square Footage"may be substituted for-Total Pmect CDst"