31-33 FAIRMOUNT - BUILDING PERMIT APP ' 1
a The Commonwealth of Massachusetts
Board ot'Building Regulations and Standards CITY
1 ty j OF SALEM
Massachusetts State Building Code, 780 C'MR, 7' edition
\ r RevisedJurrnury
Building Permit Application To Construct, Repair, Renovate Or Demolish a /. :008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Numbe�r• � � Date Applied: J j
Signature: ✓ 'wv"s ! 7/ Jed/l D
Building Commissioner/Inipector of Buildings rate
SECTION 1: SITE INFORMATION
LI Property Address: 1.2 Assessors Map d 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 11) Frontage(11)
1.5 Building Setbacks(R)
From Yard Side Yards Rear Yard
Rcquiraf 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 yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow m tofRecor �y ,/ 0 33 a
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 N mber of Units_ Ot ❑ Specify: `
Brief Description of Proposed Work': r
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building 5 1 I. Building Permit Fee:f Indicate how fee is determined:
2. Electrical S ❑Standard City?own Application Fee
❑Total Project Cosl (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
x Check No. Check Amount: Cash Amount:
6. Total Project Cost: I 5 0 0 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Icenscd Cunstr ctlo 'upervlsor(CSL) "CSLrype
0 Licenselixp z",hate
Name o1'St. _1!JJe below)
Address 0 Uexri ion
ted u to 35,000 11i Ft.d Ik2 Famil UwellinSignature Onl
ZZ�2 i RC I Residential Routing Covering
I'elcpltone WS I Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Regls mpro e t ontractor(HIC) l
I IIC Cum N r t C e t e i� Registration Number
Expiration Date
l�
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 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 ..........O No...........O
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.
Sianature of Owner Date
SECTION 7b: OWNEW OR AU RIZED AGENT DECLARATION
I ,as Owner or Authorized Agent hereby declare
that the statements and information on the to going application are true and accurate,to the best of my knowledge and
behalf r J
Print Name L
Signature of Owner or Authorized Agent Date
J.SiSES1 under the Mins and pen21tiC11 of 'u
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 gp(have access to the arbitration
program or guaranty fund under M.G.L.c. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I WAS. respectively.
2 When substantial work is planned,provide the information below:
Total floors 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"