9 1-2 INTERVALE RD - BPA-16-1269 Y e
r
MA
The Commonwealth of Massachusetts
9 CITY OF
r` ai Board of Building Regulations and Standards I
/I Massachusetts State Building Code, 780 CMR 701b NOV — I Res }EI`tr12011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This Section For Official Use only
Building Permit Number: Date Appited.
�`� DuilJing Oliicinl(Print Name). . ; Signature .. . - Date
SECTION I SITE INFORNIATION
LI pyp��ty AA dress:Ie Salem 1.2 Assessors Alap&Parcel Numbers
I.la 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(sq tl) Frontage(It)
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? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑ p
SECTION 2: PROPERTY OWNERSHIP,'
2.l��per�tot ecQr�:npA�a\ Z.�niypJl� �� �'�`L
N�1me(Pro 1' Wl --- �tty310vy 50,eyVA-@tnctiL Jyl
ZIP
5 y f/Y { e y �' I
g �
No:and Slrcet Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alterntion(s) ❑ 1 Addition ❑
Demolition ❑ Accessary Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': IV V- 000� -19
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Itcm Labor and Materials)
I. Building ; 1. Building Permit Fee:$ Indicate how fee is determined:
O Standard City/Town Application Fee
2. Electrical S ❑Total Project Costa(Item 6)x multiplier x
1. Plumbing S 2. Other Fees: S l ZS
4. Mechanical (FIVAC) S List: l
5, \ixhanical (Fire S Total All Fees:S
_Su ression)
Check No._Chick Amount: Cash Amount:_
6.Total Project Cost: S 8,00 ID ❑Paid in Full ❑Outstanding Balance Due:
MINIL3eD tt,,r� ram' EMP,1,Ul.
� Y
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisur License(CSL) vA/_`�39 )p-oN
Z/� C e A UCA S License Number Expiration Date
Name of CSL Holder List CSL Type(see below)
IV( _.,) S—I - Type - _ Description
No.an Suect
q U Unrestricted(Buildings up to 35,000 cu. 11.
R Restricted 1&2 Family Dwelling
Cily%rowe, tate,ZIP M Masonry
RC Roofing Covering
WS WindowandSidin
q SF Solid Fuel Burning Appliances
Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiation Date
HIC Company Name or IIIC R lmnt Name
dZel
No.and Street Email address
_AtrlPn
Ci /Town State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAYIT(M.G.L e. 152.¢ 2SC(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 ..........dt' No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN:
OWNER'S AGENTOR CONTRACTOR APPLIES FOR
BUILDING PERMIT
I,as Owner of the subject property,hereby authorize � �yo y 4 QJ U 1 x -
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
�\ (/q�leq�l 1 ( -01 — ((>
Print Owner's Name(Electronic gnature) 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 this application is true and accurate to the best of my knowledge and understanding.
lbse ✓I i1/iG(�� )/-I-ll?
Print Owner's or Authorized Agent's N:une(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who(tires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will nut 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
mww muss eov'oca Information on the Construction Supervisor License can be found at www.mas�
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. 11.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
'rype ofcooling system Enclosed Open
J. "Total Project Spare Footage"may be substituted for"fot:d Project Cost"