45 ESSEX ST - BUILDING INSPECTION t
The Commonwealth of Massachusetts Y� Board of Building Regulations and Standards CITY OF
J �pj: Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To ons net, Repair, Renovate Or Demolish a
One- Two-F mily Dwelling
his Section or Official Use Only
Building Per tNumber: Date lied
Building Official(Print Name) Signature ate
S TION :SITE INFORMATION
I.I Property Address: 1.2 Assessors Map& Parcel Numbers
X �!5 7V,y
1.1 a Is this an accepted street?yeses no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(11)
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 yes[]
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
J2673F/L.-}- HFAT)4 5a l , Al&q- 01,??o
XName(Print) City,State,ZIP
gs 635Z 6 r,) r-)a( Kz� A)dos,c
No.and Street Telephone mail Addre
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units 2 Other ❑ Specify:
Brief Description of Proposed Work':A 14 .
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
Q I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (fiVAC) $ List: �
5. Mechanical (Fire $
Suppression) Total All Fees: $
�j Check No. Check Amount: Cash Amount
X6.Total Project Cost: $ a b 0 paid in Full 0 Outstanding Balance Due:
t
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) /I S p&22 —I 1,Z
�ic SOV}^ +- O�lL- OnOy-C7 License(Number Expirat on Da e
Name of L f er ��
�. List CSL Type(see below)
No. and Street Type T Description
U Unrestricted(Buildings tip to 35,000 cu. tt.)
AAA R Restricted 1&2 Family Dwelling
City/Town,State,ZIP
M Masonry
RC Roofing Covering
WS Window and Siding
CJ SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2/Registered Home Improvement Contractor Contractor(HIC) C- 7 „�lq 1 v �R%(" 4' (,Y�0051Z 7 HIC Registration Number E.piration Date
HIC Com y N)uAe or HIC R•gi,61ran ame
No ditr�e^el - , ^ & 1 � �q_l / 31k
/�1 Email address
City/Town, State,ZIP Telephone
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
1,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 r5 name belc�Ny,I hereby attest under the pains and penalties of perjury that all of the information
�C
contained ' this pp ic; is true and accurate to the best of my knowledge and understanding. 9 it
Print 04per's or Vu'ihoriAAAg s Name(Electronic Signature) t 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
www.mass.eov oca Information on the Construction Supervisor License can be found at www.niass.govidns
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"
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