19 INDIAN HILL LN - BUILDING INSPECTION The Commonwealth of tMassachuszttsa - C CITY OF
Board of Building Regulations and Standards `� SALEM
Massachusetts State Building Code, 780 R��V _3 , � tevised Mur 201
,U11E Building Permit Application To Construct, Repair, Renovate Or Demolish a
(" One-or Two-Family Dive/ling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Olticiul(Print Name). Si tare - Date
I SECTION t;SITE INFORh1ATIOW
1.1 Pro erty Address: 1.2 Assessors blap&Parcel Numbers
,�A) Ig�e
I.In Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sy it - - Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yams Rear Yard
Reyuired Provided Reyuired Provided Required Provide)
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: ,_ Outside Flood Zone? Municipal❑ on site disposal system ❑
Public❑ Private❑ Check if es❑
SECTION 2: PROPERTY OWNERSHIP!`
2.1 Ownert of Record: n r� �' or 70
pCityy,Sttaat�e,ZZ,I/IPl�jC� 6
17thme(T?t)��'1't �6 28 1 W
19 >~. 1a,. ,. , 1
o.and Street
i""—'-'— Telephone Email[Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
D rS
SECTION 4: EST131ATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials)
Building
1. Building $ . lding Permit Fee:5 Indicate how fee is determine):
�a'U2� I
❑Standard City/Town Application Fee
2. Electrical S 4000 ❑Total Project Costs(Item 6)x multiplier x
3. Plumbing S Z C2 2. Other Fees: S }�
d.Mechanical (11VAC) S List: C�
5. \Iechanicul (Fire S Total All Fees:S
Su ression)
� Check No._Check Amount: Cash Amount:_
6. Tot:tl Project Cost: S V� ❑Paid in Full ❑Outstanding Bal:mce Due:
Ob h �d�
�FSPV
SECTION 5: CONSTRUCTION SERVICES
5.1 CmrstructimrSupervisor License(CSL) -1/r Number �✓ v' ✓
License um er i Er nrtion Date
RameoTCSL"f1 Holder
y ListCSL'rype(see below)
—nl It-�ILF' 17M�'T/C. �Y'JCR�i Type - Description
No.;md Street
e ��M / O I �Z3 U Unrestricted(Buildings
2Fami su tlling w. tt.
7i R Restricted I&2 Family Dwelling
Cityfruwn,State,ZTP M Imasonry
RC Rooting Covering
WS Window and Siding
M SF Solid Fuel Burning Appliances
1 Insulation
Tele hung - Email address D I Demolition
5.2 Re 'st red 14 e,{mprovement Contractor(HIC) L7 /' -7�t
q }6�p✓lG�C,.`Y•�✓/ HIC Reeg�istration Number Expiration Dade
fll�7llr y Neortiane p�
No.and ' 6,1 p2 6 )7 3'( ,6av Email address
Cl o� n State,ZIP b Te�le hone —
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...........0
SECTION 7a:OWNER AUTHORIZATION,TO BE COMPLETED.NVHEN'
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
'Print OwnName(Electronic Signature)
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 this application is true and accurate to the best of my knowledge and understanding.
tint Owner's or Authorized Agent's Name(Electronic Signature) Dale
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 no 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 etas,cov'oca hiformation on the Construction Supervisor License can be round at www.mass.^ov/dns
2. When substantial work is planned,provide the information below:
'total tloor area(sq. R.) (including garage,finished basementlattics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number or bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Ibtal Project Square Footage'may be,ubstituted for"rokd Project Cost"