25 HANCOCK ST - BUILDING INSPECTION (3) a ;
The Commonwealth of Massachusetts
chBoarde is Building i Regulations and Standards � CITY
Massachusetts State Building Code, 780 C'MR, T"eJitio OF SALEM
r Revised Junuun•
Building Permit Application To Construct, Repair, Renovate Or Demolish a ). 20AV
One-or Two-Furndy Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
glqllSignature
Building CommissioKed spector of Bu' Date
N 1:SAVIINFORMATION
1.1 Property Ad 1.2 Assessors Map dr Parcel Numbers
L l a 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 B) Frontage(11)
1.5 Building Setbacks(R)
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? Municipal O On site disposal system ❑
Check if yesE3
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of
[d f o w yt A fin, �' -
Name(Print) 7 Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK"(check al at apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Erl Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.O Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
I
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofllelal Use Only
Labor and Materials
1. Building S I. Building Permit Fee:S ndicate how fee is determined.-
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All fees:S
Check No._Check Amount: Cash Amount:
6.Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Llcen LConsiruclion Supervisor(CSL)
IJi cnse NumVrlispi do Date
Nam 01.C'SI.• old List CSL Type(see below)
T Description
Address U Unres ricted u to 15,000 Cu.Ft.
R Restricted IR2 Family Dwelling
Sig I rn M Masomy Only
RC I Residential Roofina Covering
fclephune WS I Residential Window and Sidin
SF I Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home IW van oe Coulm or(H ) i/7/ �Q
HIC Cum a or HIC Regis Registration Number
n �
AJ
Expiration to
Si It o Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 2SC(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 he building permit.
Signed Affidavit Attached? Yes .......... No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1. as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to work authorized by this building permit application.
Situtature of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and i ation on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
� I
Print N
Signalu hvne or Authori Agent Date
(Signed under the I 4ains and penalties of 'u
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 W have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I WAS,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
). "Total Project Square Footage"may be substituted for"Total Project Cost"