15 JACKSON ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7'n edition OF SALE M
,a)sI Revised Junuury
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 2008
One-or Two-Family Dwelling
T)tis cc 'on For Official Use/Onl
Building Permit Number: Dat Appli
Signature: �ll
Building Commissio r/ spcetorof it n Date
SEC ION 1: SITE INFORMATION
1.1 Pro erty Address: 1.2 Assessors Map& Parcel Numbers
-1.]a 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 11) Frontage(tl)
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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check ifyes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
N e Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addilion.NF
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work 2:�,Qrt,L'3�t-++n c7 r1 S%46 T'P" her it - 0`0
_-L)
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building S 00-0 1. Building Permit Fee: S Indicate how fee is determined:
�. Electrical S g 00 ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S x �\
4. Mechanical (HVAC) S List: [�U
5. Mechanical (Fire S
Su ression Total All Fees: S
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S 3Z 8 9 D ❑Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) �,S q9 d (9 6 — a 7
4 K ��1 /"f-iy License Number Expiration Date
Type Name of CSL-I lulder List CSL e(see below) V
P f Description
Address U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
a>zure _yam G M Mason Onl
70J d �7 �7 RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 ReR"ed Home�h pm rovement Contractor(HIC) ZJ a 17 k'
111C 0 rap y N.�n na or�I11C5FRRertmnl Name Registration Number
�1 u < hn `tJA?/o)-n 6 tJ
res -7��-�ya-�ioly Expiration Date
azure Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 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
I S (�y �'7 K , as Owner of the subject property hereby
authorize -ZO AW 709'v to act on my behalf, in all matters
relative to work authorized by thi to di permit application.
Si ature ofOw�i r— Date
//-- SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
1 v7/'1 V)94V'` " ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
i behalf. �
Print e Z
Sign re of Owner r Authorized Agent Date
Si ed under the pains and penalties of r'u
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 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 I I0.R6 and 110.115, 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"
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h. tither
l „clad Peron: _ _ Phone a:
GLORAL ASSOCIATES
Registered Land Surveyor Registered Professional Engineer
9 Broadway Wakefield,MA 01880 T:(781)246-9345 Fax:(781)246-4333
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JACKSON S-TREEr
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LOT AREA= 8284 SF
EXISTING HOUSE = 1607 SF
/// PROPOSED ELEVATOR= 209 SF Plot Plan
TOTAL= 1816 SF In
LOT COVERAGE = 22% - SALEM,MA
OPEN SPACE= 67%
HEIGHT OF SHAFT= 20' Owner
STANLEY FUDALA
�iLf/� �� (/1 • �� Scale 1" = 20' Date 6/3/2010
6/3/2010
Signature Date
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