6 INTERVALE RD - BPA-11-378 �l The Commonwealth of Massachusetts
1 W
Board of Building Regulations and Standards CITY
Massachusetts State Building Code,780 CMR,7 h edition OF SALEM
Revised January
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008
(� O -or Two Family Dwelling
/)
is Section For'Official'Use:Only
Building Permit Number: Date Applied;,
Signature: �0�2 /�7)
Building Commissioner/Inspector,ofBuildmgs,4 D"ate':
SECTION 1 uSITEINFORMATION,`
1.1 Property Address: 4f V�1 1 P 1.2 Assessors Map& Parcel Numbers
�
1.1a Is this an accepted street?yes o Map Number Parcel Number
L3 Zoning Information: 1.4 Property Dimensions:
Zoning District, Proposed Use Lot Area(sq It) Frontage(R)
1.5 Building Setbacks(ft)
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❑
SECTION 2i PROPERTY OWNERSHIPr
2.1 nert of ecor
/ Au �1 EfY ���04 iu 7 S
Name(Print) Address for Service:
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSEI)'WORI'2(check all that apply)
New Construction ❑ FExisting Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2:
/7 4A
O -f,-1 <-/+ GO
SECTION 4: ESTIMATED' CONSTRUCTION COSTS
Item Estimated Costs: . "
Labor and Materials) Official Use Only
1.Building $ 1. Building Permit Fee,-,$-Indicate how fee is determined:
2.Electrical $ ❑Standard.City/TownApplication Fee
❑Total groiect Cost-'(Item 6)x multiplier x
3.Plumbing $ 2.,Other'Fees
4.Mechanical (HVAC) $ Ltst
5.Mechanical (Fire
Suppression) $ Tote]All:Fees $ .�
Check No Check Amount: Cash Amount:
6.Total Project Cost: $
,3 � G 0Paid in Full 0 Outstanding,Balance.Due:
,4
SECTION sCONSTRUCTION,!SERYICES
� .
5.1 Licensed Construction Supervisor(CSL) 7
L C\n.{6(� License Number Expiration Date
Name of CSL-Holder List CSL Type(see below)
Address e n n 'Disspri lion
U Unrestricted(up to 35,000 Cu.Ft.
Signature j^ R Restricted I&2 Family Dwelling
M Masonry Only
Telephone RC Residential Roofing Covering
WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Re isteve H to I provement Contractor HIC)
HIC Copan Name orn-C Reg t me /) Registration Number
Address� T 7 --S f Q
—Signature
Expiration Date *;
Signature O Telephone
, SECTION 6:WORKERS'COMPENSATION INSURANCEAFFIDAVIT,(NLG.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 -
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.
b d
Si nature of Owner - - Date
SECTION.7b: OWNER§OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and informati'o- on ththe foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name �.
Signature of Owner or Authorized Agent` Date
Si ned under the pins and enalties of er'u
.--. ., . w. ..
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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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.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 heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for""Total Project Cost"