2 HART - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
Board of Building Regulations and Stand RECEIVED CITY OF
I�WE Massachusetts State Building Code, 786ftci10HAL SERVICES SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair,Renomte olio}
One-or Two-Family Dwelling `u'D` �f� H b
This Section For Official Use Only
t Building Permit Number: Date pplied:
Building Official(Print Name) signature V ` Date -
ly I SECTION 1: SITE INFORMATION
1.1 P�opKrtq A�d�ess: 1.2 Assessors Map &Parcel Numbers
1.1 aaIs this an accepted street?yes a—' 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? Municipal❑ On site disposal system ❑
Check if yes❑
SECTIO 2: PROPERTY OWNERS t
2 n i of Recors : R� O
N e(Print) City,State,Zip
10
n L
No.and Street 4.1 V ..Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction El Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration( Addition ❑
Dzmolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
/
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1. Building DAD 1 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost' (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (tIVAC) $ List: 1.24�/�()
5. Mechanical (Fire $
Suppression) Total All Fees: $
/� n� Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ � (f 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
51 onstr/ to Supervisor se(CSL) 7 S ,5_ /7,�I om License Number Expiration Date
Name 6f CSL Holder I
LIU7 �� m SL'� A-L List CSL Type(see below)
No.and trees J" Type Description
U Unrestricted Buildin s up to 35,000 Co.ft.)
R Restricted 1&2 Family Dwelling
Cityrrowli,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
'telephone Email address D I Demolition
-5.2 Regi ere �me11 iprove ent Contractor(HIC) � Q
IN.r-'rl/I h I- „�I. HIC Registration nNNumber Expiratioon Date]
pui Nani�rHIC ReQisjrcc. wayl /�,r,.�►dim &A/. (. h
V �-t W l w
N6. metre t r Email address
City/7-own, 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 APPLIES FOR BUILDING PERMIT
I, 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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW 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 th'is application is and accurate to the best of my knowledge and understanding.
/MA an a
Prin O. ner's or Authorized Agent'AkLaae ectronic Signature) Date -
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.L. c. 142A. Other important information on the HIC Program can be found at
www..nass.gov/oca Information on the gonstruction Supervisor License can be found at www.mass.gov/dys
2. When substantial work is planned,provide the information below:
Total floor 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"may be substituted for"Total Project Cost"