346 ESSEX ST - BUILDING PERMIT APP Pt The Commonwealth of Massachusetts CITY OF
< !� Board of Building Regulations and Standards
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
- - - This Section For O nal Use Only-
Building Permit Number: to Applied: z
v -p
Building Official(Print Name) - Signature �
SECTION I:SITE INFORMATION L
1.1 pe_rty Ad�reess: �l1 1.2 Assessors Map&Parcel Numbers m
1.1 a is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: Ln C'
B
Zoning District Proposed Use Lot Area(sq ft) Frontage(it)
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 Q?vne��of Record: r y 5-��Ic r /L
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WOW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Altemtion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ NumberofUnits Other ❑ Specify:
Brief Description of Proposed Workz:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 0V . 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost"(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No.JLq4-2-Check Amount: Cash Amount:
6.Total Project Cost: ❑Paid in Full ❑Outstanding Balance Due:
fn�tL.kz-o
n
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SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
$7177
License Number Expiration Date
Name of CSL Holder
Eric W.Palm List CSL Type(see below)
No.and Sneer t0t1 street
Type Description
Salem MA 01970 U 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
9-7� �, 9/t 6 SF Solid Fuel Burning Appliances
(/("[ I IInsulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(MC)
Ataantic Weatherization LLC N Z U k q 3 12 //r
MC Comppgy�IaJJ HIC Registration Number Expiration Date
pt� R�� Name
No.and Stree1l iit `s�alem 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 o e 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 �i O I/ a/pl--%
to act on my behalf,in all matters relative to work authorized by this building permit application. I�
Print Owner's ame(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contai is*I* at�" d accurate to the best of my knowledge and understanding. /
/lJ L-7
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 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
4„�.;�a.t;rass.�_ovioca Information on the Construction Supervisor License can be found at wv vv.mass.govfdos
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.R) 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"