25 HANCOCK ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
1�J Board of Building Regulations and Standards CITY
Massachusetts State Building Code,780 CMR, 7th It
OF SALEM
Revised January
Building Permit Application To Construct,Repatr,Ren ate Or Demolish a 1, 1008
One or Ttvo Family Dwellin
&trildmg f?efmtt'Nurnber � e .:, ��?ate pli(b„e
SignaUtt
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1.1 Property Addr �// C 1.2 Assessors Map&Parcel Numbers
d 5 c /r sZ
1.1a 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(it)
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 yes❑ Municipal❑ On site disposal system ❑
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Name(Print) �r T Address for Service:
y k - 31<1
Signature Telephone
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Y SECIOON 3 1)ECI> IIN* If (jjtOSED� .±Ols(I'lctecit AR that`aPP1Y)
.. .
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': . a .: 4 <ce. c v
inS /fo/
SECTION 4: ESTIMAIk)AONS1tUION"COSTS' .
Item Estimated Costs: btfieiIilseOul"
Labor and Materials
1.Building $ 1 ili]ding158 wtEFee $ _Inaicate how-fee is.detennined:
td Stk#tdard Ctty/Toun A)rphbatton Fee
2.Electrical $ Iotal.lbjee!' hem¢�x;mulUplier' z
3.Plumbing $ egg +
4.Mechanical (HVAC)
5.Mechanical (Fire
Suppression) $ TotalRiiS= ,
heck 3�1p Cheok"Amount-
Cash Amount:
6.Total Project Cost: $ 3 Cam• �l Patd iti Full, < E3 Outstanding Balance Due:
11411
�TLS .� 1'Jl{['VtILYS Y „ f
5.1,Licensed Construction Supervisor(CSL) 14C77 4 _
L License Number Expiration Date
Namef of CSL--Holder _ List CSL Type(see below) y
Address A - s p
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature T /' M MasonryOnly
13 Roofing RC - Residential Roo Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Re istere H e I provement Contragtor�rq
HIC Cc>rpan Name or HIC Re$ t me LL.. Registration Number
AddresG
/�- k,�? ��.�(� � Expiration Date
Sign-aturefLV1.L / Telephone
SECTION 6 yYQRKE CQ11')PENSAT-tQ l II$$4"I f )t�FFIDAYIT
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 ya WlYE1tAU,T)<K,W-AT10 d3ls xMull
s
OWNER'S,AGENT,.OR-CQNTR)CC-IT 'APP _ . ,P.QR Il!1 PERMIT
�— as Owner of the subject property hereby
authorize Zr rA to act on my behalf,in all matters
relative to work authorized by this building-permit application.
4
Sr na[ureofOwner Dale
as Owner or Authorized Agent hereby declare
that the statements and infortnatiorron the foregoing application are true and accurate,to the best of my knowledge and
behalf. _
L
Print Name
Signature of Owner or Authorized Agent
Date
St ed under the inns and enalhes of
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 importantinformation on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.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 halfibaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cosy'