14 GABLES CIR - BUILDING PERMIT APP '• ;
cr-
"Che Commonwealth of Ylassachusetts CITY OF
i Board of Building Regulations a��}�{ I rds SALEM
Massachusetts State Building CodP1,� 89tLwt)8 P b Revised ANur 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a'
One-or Two-Family Dwelling
This Section For Official Use Only -
Building Permit Number: Date. plied:
Building Official(Print Name). Signature• *ate
SECTION 1:SITE INFORtNIATION:
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1.Is Is this an accepted street9 yes no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq I) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yanis 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 O On site disposal system ❑
Public❑ Private❑ Check if yesO
SECTION2: PROPERTY OWNERSHW
2. wnert of Rec�orf� /
. �cfs�� Sfie/r�f s�?c2�r7 ��/J/aiJ�
t��me(Print) City,Stale,ZIP
6" l'eQ�
Nd S reef Telephone Email Address
V. SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction Cl Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) [3 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work-: i
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials)
I. Building S ��- 1. Building Permit Fee:Sill Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S 7.de,7 ❑Total Project Cose(item 6)x multiplier x
3. Plumbing $ 2,oC)&) 2. Other Fees: S
it.Mechanical (HVAC) S - List:
5.Mechanic:d (Fire S Total All Fees:S
Su reseiun) m
Check No.�gCheck Amount: Cash Amount:_
6.Total Project Cost: $ Zd, y onD ❑Paid in Full ❑Outstanding Balance Due:
'%A N, i— 70 IL z, %b
MAl LI
SECTION5: CONSTRUCTION SERVICES
5.1 Cut trt •tint Supervisor License(CSL) e 5 OEYgG7 ZG iZ
! License Number Expim[im un Uate
ra r
Nine of CS—Holder List CSL Type(see below)
-Type - Description
No.and Siren _ U Unrestricted(Buildings LIP-to 35,000 cu. 11.
dr. R Restricted 1&2 Family Dwelling
ayfrown,State,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 ti
Telephone Email address' D DemoInsulalitionon g, �--
5.2 I steredHomeImprrovementContractor(HIC)
A14 A,/o JV e- 11 HIC Registration Number E. v ton Dale
HIC Company C Regist ant Name
�t>trye Email address
No.an 4r
Cityrrown,Stale ZIP Tel e hone
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...........❑
SECTION 7a:OWNER AUTHORIZATION.TO BE COMPLETED WHW
OWNER'S AGENT OR CONTRACTOR PPLIES FOR BUILDING.PERMIT
I,as Owner of the subject property,hereby authorize M_
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
�+L�f+'2o / "r b
Print Owner's Name(Electronic Si P
ature) IDate
SECTION 7b:OWNEW ORAUTHORIZED AGENT DECLARATION
By enter.a
my name below, I hereby attest under the pains and penalties of perjury that all of the information
coat ii ed n this application is true and accurate to the best of my knowledge and understanding.
Print Owner s or Authorized Agent's Name(Electronic Signature) Date
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 nuf have access to the arbitration
program or guaranty fund under NI.G.L.c. I42A.Other important information on the HIC Program can be found at
w+vw mass ct'Woca Information on the Construction Supervisor License can be found at ww+v.mas.co+:'Jns
2. When substantial work is planned,provide the information below:
Total fluor area(sq. R.) (including garage,finished basementlattics,decks or porch)
Gross living area(sq. tt.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
I•ype of Cooling system Enclosed Open
3. "Total Project Square Foontge"inay be substinned for"'rued Project Cost"