7 HARMONY ST - BUILDING INSPECTION (2) - 2 cAc. Zq y
- aaN:� . .... .
'rhe Commonwealth of CITY OF
1 Board of Building Regulations and Standards SALEM
_ 1 Massachusetts State Building Code, 7SANA&V —4 A ReviseJbk1r2011
lV Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For Official Use Only
9 Building Permit Number: Date Applied.,
Building Official(Print N:une). Signature IM
Date
SECTION I:SITE INFORNIATIOW
1.1 Property Address: 1.2 Assessors blap&Parcel Numbers
>' LhYj ffi(w y SIT
1.l a Is this an accepted street9 yes—,(— no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(R)
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:
Zone: _ Outside Flood Zone?
Public Cl Private ClCheck if es❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTYOWNERSHIP"
2.1 O nerr of Record: C� 1
sN I AA- C' TC t V)► M �}— mot
NN me(Print) City,State,ZIP
� Mtmc\/
No.and street ITelephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ FAisory
ng Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition Cl
Demolition ❑ Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': S
VwvW S l A on:4
r SECTION 4: ESTLHATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Lab r and Materials)
1. Building C �� I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4.Mechanical JIVAC) S List:
5.Alechanical (Fire $ Total All Fees:S
Stippcession)
�ry Check Na._Check Amount: Cash Amount:_
6.'rut:d Project Cost: S W1 7 ❑Paid in Full ❑Outstanding Balance Due:
IVl Pit LEp l 1 It 0 (3
t�
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License,(CSL) .
' - License Number Expiration Date
Name of CSL holder List CSL Type(see below)
Type - - - Description
No.and Street
U Unrestricted But in a to 35,000 w. tt.
R Restricted 1&2 Family Dwelling
City/fown,State,ZIP ! M Imasonry
RC Roolin Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone. Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I:c.152.125C(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 Isivance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No...........O
S__F,CTION 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 TW-le (bvvl r�F
t9 act on my b)"e,`h'�`allf,' all matters relative to work authorized by this building permit application.
O
-Print Ow 's Name(Electronic Signature) ate
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 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 Nmne(Electronic Signature) Date
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 it�f 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
%a+ow m:as.cov'oca Information on the Construction Supervisor License can be found at ww++.mass.^o+:dns
2. When substantial work is planned,provide the information below:
'total floor area(sq. R.) (including garage, finished basementlattics,decks or porch)
Gross living area(sq. It.) 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 orcooling system Enclosed Open
i. Total Project Square Footage"may be substituted for"Total Project Cost"