91 FLINT ST - BUILDING INSPECTION t The Commonwealth of Massachusetts
i Board of Building Regulations and Standards CITY
y ) Massachusetts State Building Code, 780 CMR, 7a'edition OF SALEM
Revised Jm mirl.
Building Pr pApl cation To Construct, Repair, Renovate Or Demolish a :TRAY
One-or Two-Fumily Dwelling
This Section For Official Use Only
Building Permit Num Date Applied: cp
Signature:
Huilding missionert Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1Propertyf>IN� . S� 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 Fo Area(sq H) 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.I,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood ZoneT
Public❑ Private❑ Check if yesO Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownertot Record:
o .e__ s.0 GPsc, Af..- 01470
Nam ) Address for Service:
X r C9'98).
SignauteV Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ I Owner-Occupied)ir IRepairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. Cl 1 Number of Units I Other ❑ Specify:
Brief Description of Proposed Work:
k 77 IAA ONE A � ig 2 /a �
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Ilem Estimated Costs: Ofllclal Use Only
Labor and Materials
I. Building is I. Building Permit Fee:f Indicate how fee is Jetennmcd:
2. Electrical s ❑Standard City/Town Application Fee
❑Total Project Coslr(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (tIVAC) S List:
5. Mechanical (Fire n
Suppression) S Total All Fees:$ —C_
Check No. Check Amount: Cash Amount:
�+ 6. Total Project Cost: S 6Z''-C� 13 Paid in Full 13 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number I:.apimlion Date
Name of CSI.• I folder List CSL Type(see below)
f Description
.Address u Unrestricted(up to 35,000 Cu.Ft.
R Restricted IA2 Famil Usvellin
Signature M I Masonry Only
RC ResidemjaI Roolin covering
fclephone WS Rnidental Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
IIIC Company Name or IIIC Registrant Name Registration Number
Address I Expiration Date
Signuture Telephrme
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.as 152. f 25 M)
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 7n: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.
Si ure of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
i
as Owner or Authorized Agent hereby declare
atements and information on the foregoing application arc we and accurate,to the best of my knowledge and
_, /� _:4' n � I ( o o �a
f Owner or Authorized Agent ale
der the ins and nalties of 'uNOTES•
wner who obtains a building permit to do his/her own work,or an owner who hiresan unregistered contractor
egistered in the Home Improvement Contractor(HIC)Program), will sggl have access to the arbitration
am or guaranty fund under M.G.L.c. IJ2A.Other important information on the HIC Program and
ruction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and I IO.RS,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 of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
). 'Total Project Square Foolage"maybe substituted for"Total Project Cost"