13 GABLES CIR - BUILDING PERMIT APP • w
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I'heCommonwealth of Ma ssachu``���1�(�jFFrrTI�Nr�I. SERw `S CITY OF
Board of Building Regulations and Slf�ddaPds J SALEM
Massachusetts State Building Code, 780(CI IR N 3 �p lvised,t/ur 1011
Building Permit Application To Construct, Repair, Re t r o tsh a
One-or Tivo-Family Dwelling
O This Section For Official Use Only
Building Permit Number. Da .Applied:
Building 011icial(Print Name). - - Signature_. '—. - - Date
SECTION 1:SITE INFORMATION
Pro erty Add 1.2 Assessors Map dt Parcel Number
� Z; l iz cl�c f,
I.Ia Is this an acce led streee yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District _ Pniposed Use Lot Area(sq tl) Fmnmge(R)
1.5 Building Setbacks(R)
Front Yard Side Yards T Rear Yon]
Required Provided Required Provided. Requited Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private 0 Zone: — Outside Flood Zone? Municipol E3 On site disposal system O -
Check If esO
SECTION2: PROPERTYOWNERSHiP4
e(Print) _ Cci/�Stpte, .IP /r
Email Address
o.and Street Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKi(check all that apply)
New Construction❑ Existing Building O Owiter•Occupied O Repaints) ❑ Alteration(s) l7 I Addition O
Demolition 0 Accessory Bldg.0 Number of Units_ Other i] Specify: A:41 i P y--/W11&RS—
Brief Description of Proposed\York=:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OfRcial Use Only
Labor and Materials): - - - -
I, Building $ (�dv I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee.
2.Electrical 5 p Total Project Cost'(item 6)x multiplier x
3. Plumbing $ 2' Qther Fees: S
d.Mcchanical (HVAC) S List:
5.\fee hanicaI (Fire 5 Total All Fees:S -
Su ression)
Check No. Check Amount: Cvh Amount:
6.Total Project Cost: S Q�/ �Q 0 Paid in Full 13 Outstanding Balance Due:
w
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 1 o/ o-2-a �w^—`,b
Y( L—S 7U 14�fi 5-d L License Number Expiration Date
N:une of CSL Holder
� 9 ` �� Lis[CSL'fype(see below)�
V _
a'15- eRo� l t� Type. . . Description .
No.and Street -
t lO Y U Unnstticted BuilJin s u -el ing cu. Il.
nFny 1 R Raslricted 1&2 F:unil Dwellin
C ily own,Stale,ZIP M Maso
RC Rooling Covering
WS WindowandSidin
S I Solid Fuel Burning Appliances
1 1 Insulation
Telephone Email address D I Demolition
5p.2��Re,gistered Home Improvement
rovejment Contractor(HIC) , 7g (�/� 1j"��
Wk LL:1:4^ /� rN-I't� 271, &l,✓y HIC Registration Number Expiration Dane
I Co npan Name or HIC Registrant nine
bFl2lZO/Irr�
tplyd Street •, �7,r9) �yry qzy Email address
—A—
City/Town,State ZIP 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 Istuance of the building permit.
Signed Affidavit Attached? Yes .......... No...........O
SECTION 7a:OWNER AUTHORIZATION,TOBE.COMPLETEDWHEN: "
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING.PERMa
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) - Dale
SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name t Ellidtronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
_ (not re¢istered in the Home Improvement Contractor(HIC)Program);will ggl have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important inform ion on—the HIC-Progrn can be round at
w w.v mass eov:'oea Information on the Construction Supervisor License can be found at www.nms� .
2. When substantial work is planned,provide the information below:
'total floor area(sq. ft.) N .(including garage, finished basement/attics,decks or porch)
Gross living area(sq. It.) 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
1. `"total Project Square Footage"may be substituted for"'fot;d Project Cost"