6 HARBOR VIEW TER - BUILDING INSPECTION (2) The Commonwealth of Massachusctts
Board of Building Regulations and Standards CITY
Massachusetts State 1 Building Code, 780 CMR, 7'"edition OF SALEM r Rrvisvr/Junmvr
Building Permit Application To Construct, Repair, Renovate Or Demolish a /. :rxtiY
One-or rtvu-Family Dwelling
This Sectio For 0(ricial Use Only
Building Permit Nu bar: Date Applied:
Signature:
Building ConlWiffiditer to of Buildings Date
SECTION 1:SITE INFORMATION
1.2 Assessors Map& Parcel Numbers
lu.la Is this sanlaccepted street?yes no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dlmeoslona:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(II)
From Yard Side Yards Rear Yard
Required Provided Required Provided Required r 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?
Public O Private Cl — Check if cs❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Nam/e((�.m)Q Y Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check sill Chet apply)
New Construction O Existing Building❑ Owner-Occupied O Repairs(s) ❑ 1 Alteration()) O Addition ❑
Demolition O Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
�L.
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated C0313: OOlclal Use Only
Labor and Materials
I. Building S 1. Building Permit Fee:f Indicate how fee is determined:
❑Standard Cityfrown Application Fee
2. Electrical $ G . ti ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S Z. Other Fen: S
4. Mechanical (IIVAC) f List:
S. Mechanical (Fire Su ression) S Total All Fees�S_____-
Check No. Check In : Cash Amount:
6. 1 Protect Cost: S�f/��� ❑Paid in Full O Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) � / /
���'� �/- I '%nse Numbs` , Expiration Date
N�.•I tinder O /
List CSL type(see below)
f Dricripoion
:�JJresa /��tP�S�o PDRaidential
restricted u to J3.0W Cu.Ft.stricted 1&2 I' mil IJwellinw Onlidential Routin Coverinfelaplkme / / idential Window and Sidinidntil Sulid Fuel Buin A liamc Imtallatiun Demolition
5.2 Regbte me Improreme I Coa�lor(HIC)
iw� Qu —' Registnuion.Namlter
I IICI Com—y l'lameTsue FIIC Registrant N• a
Adtfiess � ^ Esptration Due
Siynu relephwie
SECTION : WORKERS-COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. Ill.S 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 of the building permit.
Signed Affidavit Attached? Yes..........a No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize_ Yi�1 GIaS r 17G to act on my behalf,in all matters
relative to work nuiltolized by this building permit ap$lication. (/
Si are of Owns Date
SK,QTION 71b: OWNEW OR AUTHORIZED AGENT DECLARATION
I — as Owner or Authorized Agent hereby declare
that the stateme d info on on the foregoing application are we and accurate,to the best of my knowledge and
f.behal
i
Print Name Z//
Signature of Owner or Authorized Agent Date
(Siuncd under the pains and penalties of 'u
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-W have access to the arbitration
program or guaranty fund under M.G.L.c. M2A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I I0.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 half/baths
Type of Beating system Number of decks/porches
Type of cooling system Enclosed ()pen
J. 'Total Project Square Footage"may be substituted 1'or"Total Project Cast"