6 FAIRFIELD ST - BUILDING PERMIT APP The Commonwealth of Massachusetts CITY OF
UlfBoard of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Family Dwelling
,s�Ttus Section For OfFictal��Tse Only
Building Permit Number
Building Official(Print Name) Srignat ,„ F Date', -`
SECTION 1 $ITE NFO E .>
1.1 Property Address: 1 Assessors p-& Parcel Numbers
L la Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq fit) Frontage(it)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal H On site disposal system ❑
Public t9✓ Private El Check if yes❑
SECTION'!: PR0K4T OWNERSHI]?'''
2.1 Owner'of Recorll: � of L��vt rn
Name(Printt)/ / City, State,ZIP �+ B✓t-er ✓l. '('..-2Ul-Qi(�
�n 7�.A'Cy/GiY jG�L� s� `� � �����(�� ! k-C�-Q ! �J 'l.,
No.and Street Telephone Email Address
SECTION 3:.DESCRIPTION OF PROPOSED WORK(check all'that'apoly)
New Construction Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': /�5GL —
L �fY07
SECTION 4: ESTTMATED.CONSTRIJCTION COSTS._$. '.
Estimated Costs: �# -official Use Only =
Item Labor and Materials
1. Building $ L. Building Permit Fee $ Indicate haw fee is determined.,
❑ Standard City/Town Applicabon Fee
2. Electrical $ U ❑Total,Prolect Cost (Item 6)_xrgulriplier x
3. Plumbing
4. Mechanical (HVAC) $ List
5. Mechanical (Fire
Su ression $ Total,All Fees $ -
Check No. Check Amount Cash Amount
6. Total Project Cost: $ �' (� ❑paid in Full:, I Y Outstanding Balance'Dpe
SECTION 5: CONSTRUCTION SERVICES
r5.1Construction Supervisor License(CSL)
License Number Expiration Date of CSL Holder
List CSL Type(see below). nd Street ;TXP.e Description
- U Unrestricted(Buildings u 2 to 35,000 cu.,ft.
R Restricted I&2 FamilyDwelling
City/Town, State,ZIP M Mason
Ly
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
H
HIC Company Name or HIC Registrant Name IC Registration Number Expiration Date
No. and Street Email address
[Signed
/Town, State,ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFLDAYIT(M.G L:cC152:§ 25C(6))
orkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
s affidavit will result in the denial of the Issuance of the building permit.
it
Attached? Yes .......... ❑ No ........... ❑
SECTION 7ar OWNER AUTHORIZATION TO BE-COMPLETED WHEN ,t.
OWNER'S AGENT OR CONTRACTOR APPLIES FORBUILDING PERMIT'
I, as Owner of the subject property, hereby authorize
tLacon my behalf, in alltna ers relative to work authorized by this building permit application.
_t
print Owner's Name(Electronic Signature) Dat
SECTION 7bOWNER''OR'AUTH6R[ZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES: -
I Ev
wnerwhoobtainsa building permittodohis/herownwork,oran ownerwho hiresegistered in the HomImprovmnt ContractoHIC) Program),willnothaveacceam or guarantyfund under M.G.L. a L42A. Other important information on the HICtnass.�>ov%oca Information on the Construction Supervisor License can be found at www.mass.eiw4lns
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"