53 HANCOCK ST - BUILDING INSPECTION TheCommonwealthofMassachusetts RECEIVED
Board of Building Regulations and Standa406PECTIONAL SE RV1C@SY OF
Massachusetts State Building Code,780 CMR SALEM
BuildingPermit Application To Construe Re eV4!- Mar 2011
pp t, pair,Renovatej�l�iofi�l aP 4
One-or Two-Family Dwelling
This Section For Official Use Only. -
Building Permit Number: Da pplied:
Building Official(Print Name) - ! Signature - - - Date
SECTION 1:SITE INFORMATION
1.1 Pro arty= /' 3
1 1.2 Assessors Map&Parcel Numbers
1.l a Is this an accepted street9 yes_ no Map Number Parcel Number
11\y\L 1.3 Zoning Information: ( 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.71 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1,M °`u�°'� 5,�-e f Sal 0rs70
Name(Print))' /I City,state,ZIP
: 7i f7GN L Ca k S�. 7y�r- CIOn
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Building❑h Owner-Occupied ❑ Repairs(s) ❑ L Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 11,Number of Units_ Other Specify: �Jj, {Q ✓jam,
Brief Description of Proposed Work2: I
SECTION 4.ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
or and Materials y
1.Building $ r S�- 1. Building Permit Fee:$ Indicate how fee is determined:
2 Electrical $ I ❑Standard Cityffown Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ I 2. Other Fees: $
4.Mechanical (HVAC) $ ` List:
5.Mechanical (Fire
Suppression) $ I Total All Fees:$
�y� Check No. Check Amount Cash Amount:
6.Total Project Cost: $/' i-a , El Paid in Full ❑Outstanding Balance Due:
StENT %ZA 1�
SECTION 5: CONSTRUCTION SERVICES
- 5.1- Construction Supervisor License(CSL) S .7 C-7-7 3
-- - - -- _ _ - _- -License Number - -Expiration Date ---
Name of CSL Holder
Eric W. I'Ldm List CSL Type(see below)--IA—
No,and Street rT "`'` TYPe Description _
Salem MA 0fi970 U Unrestricted(Buildings up to 35 0 00 cu.fl
R Restricted 1&2 Family Dwelling
CityRbwn,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
9-IV714 4` ' SF Solid Fuel Burning Appliances
D -I [ 1 Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
i 1 LiZvg-q
Atlantic W et17A( p i T(' HIC Registration Number Expiration Date
HIC Company Name or HICArgi e Nam
erSCd
V�ll_e
No.and Street Ul Salem MA 01970 Email address
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 issuance of the building permit.
Signed Affidavit Attached? Yes ........�. No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR"PLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby i rthorize Cr►'t.G Ca l yYl
to act on my behalf,in all matters relative to,work authorized by this building permit application.
04'd��t�` m.n LX I / ZI elt q
Print Owner's Name(Electronic Signature) I Daze
SECTION-7b:OWN I
this applica n is true and acc IllEW 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 accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
I 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.LI c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/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.) I (including garage,finished basementlattics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces I Number of bedrooms
Number of bathrooms I Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
i