0005 HOWARD STREET - BPA-15-1078 i
'rhe Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards RECEIVED SALEM
I / Massachusetts State Building Code, 78PjGW9;TJOWlL SERV CES isedMar2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling ZoI5 OCT —5 A
r This Section For Official Use Only
0 Building Permit Number: Date.Applied:
l0 y I�
t Building Otticial(Print Name). ' Signature: W . . Date
SECTION I:SITE INFORVlAT10rC
I.1rPro1perty Address: 1.2 Assessors flap&Parcel Numbers
lri,_•I. I.I a[-'his an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sy tl) Frontage(It)
1.5 Building Setbacks(
Front Yard Side Yards Rear Yard
Reyuin:d Provided Required Provided Required Provide)
1.6 Wnter Supply:(M.G.L c.do,§Sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if YeII3
I , + SECTION2: PROPERTYOJVNERSHIPf
2.1 OG ner�f R,�cotu,rwnh. K,r�tM
City,State,/I/P
�J9 �/JiPI. .J t�l�Ottr/C `7�J1 �H4�/8�
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED-WORKS(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ I Addition ❑
Demolition C) I Accessory Bldg.CJ I Number of Units_ Other ❑ Specify:
Brief Descriptio o'Pr posed\VorV: —
SECTION y:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ ,ram 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 S I3 VVv .p%;, P 9ther Fees: S
d.Nlechanical (HVAC) S List:
5. \lechanic:d (Fire S `• Total All Fees:S
Sop ressiun)
Check No._Check Amount: Cash Amount:
6."total Project Cast: S fO�i (gtyl7.Oe ❑Paid in Full ❑Outstanding Balance Due:
1011
L tCC CSC TD I 'laid I'r�u—
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
E
License Number .epimtion Date
Name of CSL Holder
/� L� List CSL"type(see below)
4, g V�Ce�rl�,nrA �Y Type Description
No. and Street
U UnresuicteJ Ouildin s u i to 35,000 cu. ft.
Q,J w..W1 VAN— DZVGC1 R Restricted I&2 Family Dwelling
Cilylfown,Sta , IP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Bruning Appliances
Z 1(y.p rei j V p�Lfj�l_�.cs t I Insulation
Telc hone &nail address D Uemolilion
5.2 Registered
— [tome Improvement Contractor(HIC)
J
Jyald o A Lkfy aj, HIC Registration Number Espirution Date
HI,G Con any No e r HIC Registrant Name
11I l rtvt.0 c_P.�u'r
NA rand Street � (O A ?1 Emuil a t res
City/Town,gUte,ZIP Telephone
SECTION 6:WORKERS'CONIPENSATION 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 Is;uance of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION.TO BE COMPLETED)VHEN•
OWNER'S AGENTOR CONTRACTOR APPLIES FOR BUILDING PERMIT
,, as Owner of the subject property,hereby authorize E0QJ0 U e;,n'rJ(i,to
t9 net on my behalf,in all matters relative to work authorized by this-building permit application.
_ lo -alr
Print Owner's Name(Electronic Signalu Dale
SECTION 7b.OWNERt 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 this application is true and accurate to the b st of my knowledge and understanding.
H , t0 —O
Print Owner's or Authorized Agent's Name(EI ctromc ignal Date
NOTES:
I. An Owner who obtains a building permit to Jo his/her own work,or aftowner 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. I42A.Other important information on the HIC Program can be found at
www mass.eov:'oat Information on the Construction Supervisor License can be Found at www.�u .
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 half/baths
Type of heating system Number of decks/porches
Typeofcoolingsystem Enclosed Open
3. "Folal Project Square Footage"may be substituted I'or"ToCd Project Cost"