56 FELT ST - BUILDING PERMIT APP ,
7�ad �-
The Commonwealth of Massachusetts CITY
Board of Building Regulations and Standards OF SALEM
I Massachusetts State Building Code, 780 CMR, T°edition
Revised lmuavv
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 2008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied: O ti l J
Signature: y/ ! d
Building o oner/Inspector of Buildings Date—r_—r
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
I.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)
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 O On site disposal system ❑
Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Swr1 ./,d C
Name(Print) Address for Service:
q--2 x -7 q 4 -�y
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 Existing Buildi Owner-Occupied Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':_. -S
`s
C C92 ea G1-4 6 & +st Ae
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical S ❑Total Project Cast'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Su ression
q p Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 1 D 1 p��p ❑Paid in Full ❑ Outstanding Balance Due:
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) (v. 5_ I y _ `�
License Number Expiration Date
Name;
)IQL- I Iolder List C (se CSL Type e below)
�.rh
AJdres Type I Description
� C2 U I Unrestricted(up to 35.000 Cu.Ft.
It I Restricted 1&2 Family Dwelling
Sig mre M I Masonry only
RC I Residential Roofing Covering
Telephone WS I Residential Window and Siding
SF I Residential Solid Foci Burning Appliance Installation
D I Residential Demolition
5.2 Registered Hp a Improvement Contractor(HIC) t7
o_� (z✓Z V C.r�ti
HIC Cumpany Name or HIC Registrant Nam Registration Numbe
AJJ�re� _5 —'_ _ 9,,$53 1 $1,3-" Expiration Dale
Signatures 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 ..........Cl No...........0
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.
Signature of(Tuner Dole
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, L C, b—o Ly Iy�y aeT ,as Owner o uthorized Agen ereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner o utho"rized A e � Date
D — 1 O
(Signed under the pains and naTiles 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 W 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 110.116 and I I0.R3,respectively.
_'. 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 or 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"