21 FOWLER ST - BUILDING INSPECTIONi
The Commonwealth of Massachusetts y+y
�y Board of Building Regulations and Standards CITY
0 Massachusetts State Building Code, 780 CMR, 7w edition OF SALEM
Revised January
Building Permit Application To Construct,Repair, ovate Or Demolish a 1, 2008
One-or Two-Family Dwel • g
ht S&tion ForO t Use Only
Building Permit Number: ate Applied: Z 4u cJ,
Signature:
Building commiss-14ertYnspectordf u'drags ;Date' 1
SE t)N 1:,SITEINFOB113ATION
1.1 Property Address: 1.2 Assessors Map&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 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?
Check if yeso Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY-'OWNERSHIP'
2.1 Owner'of Record- -
,1 k �CJ
Name(Print) �� _c Address for Service: I 7
�,g- ztzz
Signature Tel—e�e' --
SECTION 3.I)ESCRIPTIO,IV OF PRQPOSED'VVORI{z(check-all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': Zz-
SECTION 4: ST ATED CONSTRUCTION COSTS,
Item Estimated Costs: Official.Use Only
Labor and Materials Y
1.Building $ "L.Btiitdmg Pertfiit Fee: $' Im3icate how fee is determined:
2.Electrical $ '❑Standard,-City/Town Application Fee
❑Total-Project Cost',(Item 6)x multip
Other lier x
3.Plumbing $ 2., �Fees` $; '
4.Mechanical (HVAC) $ List: :.-: -
5.Mechanical (Fire
Su ression $ Total All-Fees $,
6.Total Project Cost: $ /7 Check No Check Amount: Cash Amount:
3 w ❑Paid•in Fuli ❑Outstanding Balance Due:
a SECTION Si CONSTRUCTIONSERYIGES ,
5.1 Licensed Construction Supervisor(CSL)
t° License Number Expiration Date
Name of CSL-Holder y
h �',('�.{�..�w UlJ �.-I) IDS List CSL Type(see below)
Address /n.�.�� T '•' Description
aa U Unrestricted(up to 35,000 Cu.Ft.
y/� R Restricted l&,2 FamilyDwelling
Signal
.� M MasonryOnly
' � RC Residential Roofing Covering
3 3
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Re 'stare H e I tprovement Contract (HIC) 4:� S_�
HIC Co 7Name or C Reg nt e L. Registration Number
Address I -ice Expiration Date
/Q
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 AUTHORIZATIONTO BE,COMPLETEI)WHEN ,
OWNER'S AGENT OR CONTRACTOR APPLIES3FOR BUIEDING=PERMIT = °
I, as Owner of the subject property hereby
authorize `��� u ,-�.t to act on my behalf, in all matters
relative to work authorized by this buil g permit application.
Signature of Owner - Date
SECTION74 OWNER;OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and informatio on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Ageltt Date
Si ned under the pains and penalties of perjury) -
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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.R5,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"maybe substituted for"Total Project Cost"