28 GABLES CIR - BUILDING PERMIT APP • �� 2� e.r�I cis
The Commonwealth of Massachusetts CITY OF
C' Board of Building Regulations and Standards SALEM
(jo Massachusetts State Building Code,780 CMR Revised Mar 2011
(O Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For OPftcial Use Uel "
Building Permit Ahmtber: Date Applied:
Building Otiteial(PriirtName) $igitaba'e (P 60
SECTION 1:SITE I]!iP0R3kIATdON'
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
—2- C-r-A S C l e.c_L-e- 1 0 22 $ -d
1.Is Is this an accepted street?yes no Map Number Parcel Number
1.3 Z1.3 Z ingInformation, 1.4 Property Dimensions: F
V'Q�O(3
Zoning District Proposed Use Lot Area(sq ft) Frontag ($)
1.5 Building Setbacks(}t)
Front Yard Side Yards hear Yard
Required Provided Required Provided Required Provided
G (o
ri Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public PrivateJV
Zone: _ Outside Flood Zone? Municipal Pit site disposal system ❑
Check if es❑ _
SECTION 2- PktOPERTYOWNNRS11(lEP'
2.1 pwn er'of Record: lem M n / O
s�IlA 13x19L �A
Name(Print) City,State,ZIP
28) Gates C1i2 97g9'7Ay�8% I/samRsz!/a 13 f�hnt a�
No.and Street
Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK$(eliecJc all tbat aPP1Y)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ /
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other Specify: P J I 2 R
Brief Description of Proposed Work': /V 11 ' ovNU 0 r- xov n - G i'
'iA clEti /tl d,� ouN n
iz Kr n eO
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only .
Item (Labor and Materials - -
1.Building T 0 o L $ 710 1. Buili�og Femtit Fee:$ Indicate how fee is detemtined
❑Standard C41Town Application Fee
2.Electrical $ S� ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees;
4.Mechanical (HVAC) $ List:
5.Mechanical (Five $ Total Ali Fees:$
Su cession
Check No. Cheek Amount: Cash Amount:
6.Total Project Cost: $ 11 Sa °= ❑Paid in Full ❑OuWan!!!!g Balance Due:
O
SECTION S CQN7RUCiTQNiSERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street
Type � serlption.
U I Unrestricted(Buildings up to 35,000 cu.R
R I Restricted 1&2 Family Dwelling
Cityfrown,state,ZIP M I Masonry
RC I Roofing Covens
WS I Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registraht Name
No.and Street Email address'
City/Town,/Town,State ZIP Telephone
SA,SECTION 6:WORKER COMPENSATION INSURANCE AFFIDAVIT(NLGJ- c.152.§ 25C(6))
Workers Compensation Insurance affidavit roust be completed and submitted with this application. Failure to provide
rthis affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No...........❑
SECTION is:OWNER AUTHORIZATION TO BE COMPLETED WIIEN
OWNER'S AGENT QR CONTRACTOR '/APPILMFQR ING
1,as Owner of the subject property,hereby,authorize • M i/ lkSQA I1/h /.rGAA eL P 44 61/
to act on my behalf,in all matters relative to work authorized by this building permit application.
cT 1pjgSe- A/ la Ca
Print Owner's Name(Electronic Signature) Date
SEC7I014 7b:OWNEW 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(Electronic 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 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 can be found at
MMMass.sov,'oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementtattics,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"may be substituted for"Total Project Cost"
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