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The Commonwealth of Massachusetts
y;►, .� Board of Building Regulations and Standards CITY
t Massachusetts State Building Code, 780 CMR, 7ih edition OF SALEM
Revised January
�✓�/ Building Permit Application To Construct,Repair, Renovate Or Demolish a /. 200.4
One-or Two-Family Dwelling
/11 This Section F Official Use Pnly
Building Permit Numb ate Vplic
Signature: J i
Building Commissioner/Inspectoruf Buildings Date
SECTION I:WE INFORMATION
1.1 Prpperty Address: 1.2 Assessors Map& Parcel Numbers
1.la 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(11)
1.5 Building Setbacks(R)
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?
Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.t Ownert of Rec d _\
Name(Print) Address for Service:
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': S1 C c, V6
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OMclal Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
1. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
6.Total Project Cost: S Check No. Check Amount: Cash Amount:
Q 13Paid in Full ❑Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
t �
5.1 Licensed Construction Supervisor(CSL) \0,'.S�r,\--) n31 t LI
License Number Iispimuun Date
Name of CSL• lulder List C'SL Type(see below) �—
30 ��
f. Description
:WJress IlnreslricteJ(up to 35,000 Cu.Ft.
R Restricted I&2 Family Dwelling
SignatureG M Masonry Only
RC Residential Roolina Coverin
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Bumm Appliance Installation
D Residential Demolition
5.2 Ree t,ry , omelm��ln�eot`Co�ntnctor(HIC)
�'�\ �'�� Registration Number
[tic Company alrte or 111C Registrant Name ��
O �!� 1�
Address 99
�..���`p�"1"�"� Expiratioh Date
4==� ��t �
Signature 'telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a 152.f 15C(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...........O
SECTION 79:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, 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.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
11� S\\-A"--.� ,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 Name /� f
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
NOTES:
I. 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 n r have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 750 CMR Regulations I IO.R6 and 110.115,respectively.
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 of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"