1 ISLAND AVE - BUILDING INSPECTION (3) ' The Commonwealth of.Massachusetts
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Board of Building Regulations and Standards CITY
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Massachusetts State Building Code,780 CMR, 7b edition OF SALEM
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Revised January
(vim` Building Permit Application To Construct, Repair,Renovate Or Demolish a 1, 2008
One--or Two-Family Dwelling
This'Se¢tioa For Offieial Use Only "
Building Permit Number: Date Applied: 7i - / 0
Signature:
i g" Ba'Idmg9, , D- �
-Bu ldin Commissioner/Inector of
• SECTION 1 SITE`,INFORMATIUN
1.1 Property A rens:/ r 1.2 Assessors Map& Parcel Numbers
1.1a 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 ft) Frontage(fu
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 sy tem ❑
Check if yes❑ is
SECTIONS PROPERTY-OWNERSHIPS
2.1 Ow
yper of Record:,// / C
Name(Print) Address for Service:
Signa Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKZ(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 :
SECTION 4: ESTIMATED`CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee,: $'Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee -
❑Total,Prolect Cost'(Item 6)x multiplier x
3.Plumbing $ 2.,Otber'Fees $ "
4.Mechanical (HVAC) $
5.Mechanical (Fire $ �
Sup ression) Total All Fees;$ "
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑paid in Full ❑Outstanding.Balance:Due:
n SECTIONS CQNSTRUCTIOMSERVICES, ."
5.1 Licensed Construction Supervisor(CSL)
/1A (CA, a L C��6(--. License Number - Expiration Date
Name of CSL--Holder List CSL Type(see below) y
AT, "De`sbri'tion.
ddress
j f j° U Unrestricted u to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature - i M Mason Only
l 4� —:2 S�tS 3 (3 RC Residential RoofingCovering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation `
D I Residential Demolition '
5.2 lk ister_e H to I provement Contragt r(HIC)
c L
HIC Co +Name or C Reg t nt a Registration Number
Address _ 7 - L D
m-1, � ,� J7k--7(/,�r-Q'313 _ Expiration Date
Signature Telephone J
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 BUIGDING,PERMTT > .k
1 I� / X 13 v : S as Owner of the subject property hereby
authorize G��� /t c�' roc to act on my behalf, in all matters
relative to work authorized by this building permit application.
Signature oftJ'wner - Date
SECTION 7b:OWNER'ORAUTHORIZEI)AG,ENT.DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and infotmatio on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
L l
Print Name
� 7A ,✓L �Y
Signature of Owner or Authorized Ageat Date
(Silzried.undcr the pafiis and enalties of r'u
.'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 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.) (inc[uding 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 ».Fe' Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"