4 FAIRFIELD ST - BUILDING PERMIT APP , fhe Commonwealth of Massachusetts
CITY OF
/� ,i• . Board of Building Regulations and Standards SALEM
(� t: Massachusetts State Building Code, 780 CMR Rrvised.thur 2011
tO1J� Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Ttvu-Family Dvelling
This Section For Official Use Only
Building Permit Number: I Date Applied: f
'4f t4 R e' lt' A 1
Building Official(Print N.une) IS gna Date
SECTION 1: SITE I ORDIATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
'�'Fcalr�al�/ c?
I.I 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(sy tl) frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Reyuircd Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.J0,§Sd) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal System [3Public❑ Private O Check if cs[3 P y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: s
I'-.�lGL !�Pn4/. R/ �/Y/.„ Pt So/Gm MA c,1y 70
Nimte(Print) City.State,ZIP
HJQ)rKile/d ST 9-2&.S --so11
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairsls) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': Q� -- - -/- ,Fh �.0 p�LS'1S'�'^ G
7i 't C
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials)
I. building S l� I. Building Permit Fee: S Indicate how fee is determined:
❑ Standard City/Town Application Fee
' Electrical S / 9£f t
❑Total Project Cost (Item 6)x multiplier xn
3. Plumbing S SOCaco 2. Other Fees: S
4. Mechanical ( 1V\ C) S List: (/�f
i, ;\lechanicel (Fire 5 Total All Fees: S
Suppression) —
Check No. Check Amount: Cash Amount:--_
G. Total Project CusC S /i Z eJe6s ❑ Paid in Full ❑Outstanding Bal:mce Due:
=Street ---
ECTION 5: CONSTRUCTION SERVICES
Construction Supervisor License(CSL)
�y) _q1 G -j�rAl�al ip< _ License Number Expiration Date
IuWcr •List CSI-Ty pc(see hetow)�k Jr y' Type Description
TQwksd u> , U I lnrestrictcd(Buildin�s no to 35,000)cu. 11.)
R Restricted la&21'anuf D+cellin
Citylll+wn.Snnc,ZIPS-- M Mason It Boutin Covcrin
W'S Window and Sidon
SF Solid fuel Burning Appliances
Insulation
Fele hone E=* -
ail address U Demolition
red Home Improvement Contractor(HIC)G� R De �cn N:un or I IIC Registrant fineHIC' Registration Numhcr fizpiration Uutc
,.,�� P.� a , 6 t!�(L /Ye7 1^r^ v P r/ten e./?O
er5 MA ���-� �77f/_��y-PJGY? moil aJJ sstate,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c. 152.1 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
[I. as Owner of the subject property,hereby authorize � enoRact on my behalf,in all matters relative to work authorized by this building permit application.
Print Owners Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
I
ering my name below, I hereby attest under the pains and penalties of perjury that all of the information
ned in�this application is true and accurate to the best of my knowledge and understanding.
%, same(ID++ner s nr \uthonzed Agent's N;une I I.Iccuunic.Signature) Dute
NOTES:
Owner who obtains a building permit to do hisiher own work,or an owner who hires an unregistered contractor
t registered in the Home Improvement Contractor(HIC) Program),will not have access to the arbitration
gram or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at
+�1-i]cu..59):. 'e,7 Information on the Construction Supervisor License can be found at gy++r.iva;: �o�;Jl;,
en substantial work is planned,provide the information below:
uor area Isy. ft.l (including garage, finished basemenC'attia,decks or porch)
iving area(sy. If.l Habitable room countr of fireplaces-_____ Number of bedrooms --------
Number of bathrooms
--------------_---- Numben,fhalt:badts
1)pe of heating system
-------------- --
Number of Decks. porches
i)pcorcoolingsystem - ---- ------
I::nclox:d _ _ Open
------ ----
3. "focal Project Square Footage-may be substituted for''Lotal Project Cost'
-----------
...... ..
------ ..----
�_ � Ii ,
-------------
--- ---- ---
ZZ/
_ _ __ _ _ __ _�___ __ __ __ _ ..... __ _ ___t C __�_ __ __� __I_ _� _ __ ___F