3D FILLMORE RD - BPA b-11-460 1
The Commonwealth of Massachusetts
�- Board of Building Regulations and Standards CITY
OF SALEM
Massachusetts State Building Code, 780 CMR, Th edition Revised✓tn uary
sss Building Permit Application To Construct, Repair, Renovate Or Demolish a ). 2008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Numbe ./f�,,..,,, Date Applied:
Signature: vAt-"-
Building Commissioner/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
3D��eegr,o � d,
1.1 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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system
❑
Public❑ Private ❑ Check if yes❑ P P
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
Jim Nlltle c 1fo s 3 D Fi/-[ c r> 0of- R0
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ElRepairs(s) ❑ Alteration(s) 01 Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work-:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (BVAC) $ List: �-
5. Mechanical (Fire $ Total All Fees: $
Suppression)
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 3, o oa,a 0 0 Paid in Full 0 Outstanding Balance Due:
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 0,;0 ec S / a/o
fhAx( a7i�—g License Number Expiration Date
Name of CSIL I1o1d•r r
1 4 �i, _ L?&C List CSL'Type(see below)
Address /•""��r"' •'l^ _ �n ( Description
Ft
lJ l lnreslricteJ u to 35,000 Cu. Ft.
It Restricted 1&2 Family Dwelling
Signature n M Masonry Only
QC RC Residential Roulin•Covering
1'elephone WS Residential Window and Siding
17 9; --7Ys 3-5
SF Residential Solid Fuel 13umin•Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) /d v
HIC Company �(ame or H ' Registrant Name Registration Number
Address /IJ�` , /�p� G�/d �/
' 7 77e-7Y)—5'S-k- Expiration Dale
Signature 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 .......... ❑ No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, J - , 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 Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
I, as Owner or Authorized Agent hereby declare
that the statemen and informs ion on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
RGa _
Signature of Owner or uthonzed Agent Date
(Signed under the pains and penalties ofperjury)
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 Flome Improvement Contractor(HIC) Program),will trot have access to the arbitration
program or guaranty fund under M.G.L.c. 1 d2A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I0.R6 and 110.115, 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 halfibaths
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"