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28 FAIRMOUNT ST - BUILDING JACKET 0 2zl b ScQ I� - I LA - 2- 4, The Commonwealth�Q#� SERVICES Board of Building Regul�tlJjs an Standards CITY O SALEM Massachusetts State Building Co Neo`47ffN ID 30 Revised Mar 2011 Building Permit Application To Construct, Prepatr, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: it 13 14 Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Prope y Address: 1.2 Assessors Map& Parcel Numbers 0 5+ 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(sq ft) Frontage(ft) 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.J, Owner'of Record, bcitt1n Md 0/770 Name(Print) ` City, State,ZIP t� Ctr /rnn, xV��. 97�'' 7YS Gj,7 3�- No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑ Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify: Brief Description of Proposed Work': y\.5 S- 0. a ©o 4 /�Iti()L_en rco SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ —7 �_ 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑ Standard City/Town Application Fee ❑ 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. Check Amount: Cash Amount: 6.Total Project Cost: $ ❑ Paid in Full ❑ Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) �/ l 6S-r� carp sad->� t ,fit trr_S .9v--Z License Number Expiration Date Name of CSL Holder ' List CSL Type(see below) 1/ — /Vo/� 51 No. and Street Type Description � �. 0 1�, ^,.16 U Unrestricted(Buildings u to 35,000 cu. ft.ex.(,C-y✓t R Restricted 1&2 Family Dwelling Cny/Town, State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) / -4— A-s7et ,/1 CR.S IKG - HIC Registration Number Expiration Date HIC Companyy Name or 1-I1 Registrant Name MS1�lo ✓ If � Jl No. nd Street Email address �a 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 .......... V 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 ' t y r S 20 -2 to act on my behalf, in all matters relative to work authorized by this building pernifit application. 5� esz (0yx� "I-13- 1q Print Owner's Name(Electronic Signature) Date SECTION 7h: OWNER' OR AUTHORIZED AGENT DECLARATION Bye ring my name below, I hereby attest under the pains and penalties of perjury that all of the information cont ' d this a lication is true and accurate to the best of my knowledge and understanding. Ilk-1"3 -1y Print Owner's or Authorized gent's Name(Electronic Signature) 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.aov/oca Information on the Construction Supervisor License can be found at www.mass.zov/dps 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"