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401 JEFFERSON AVE - BUILDING INSPECTION The Commonwealth of Massachusetts Board of Building Regulations and Standardsj Town of Massachusetts State Building Code, 780 CMR, 7'"edition Building Dept d Building Permit Application To Construct, Repair, Renovate Or DeOne- or Two-Family gThis Secti or Official Use Only Building Permit Number: Date ppl'ed- Signature: i r1!1, Building Commissioner/In ector of Built s ate SECTION 1: SITE INFORMATION I.1 Property Address: //����-- 1.2 Assessor Map& Parcel Numbers fC O 1 J �f r Prho� A—c9 r� , )' / I.1a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: !A Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(II) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required ovided Required rovided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private O Zone: _ Outside Flood Zone?Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner[ Kec r Name(Print) ' 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) ❑ Addition ❑ Demolition y Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': --��� 'QED ••S ''nS � •"L4 o+n/> Sl JC Alan^ 0 00 La I SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Offlcial Use Only Labor and Materials I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ ❑ Paid in Full ❑Outstanding Balance Due: 4 Ll SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) 9 T O q 1 ••- License Number Expiration Date N.qme of CSL- Helder List CSL Type(see below) - T -Description U Unrestricted(up to 35,000 Cu. Ft.) R Restricted I&2 Family Dwelling Sig at r �,,, M Mason Only '�'�C/ RC Residential Roofin Covering Telephone WS Residential Window and Sidin SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition - 5.2 Registered Home Improvement Contractor(HIC) HIC Company Name or HIC Registrant Name Registration Number Address Expiration Date Signature Telephone 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........... 13 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT L'/.f/jT/;'as Owner of the subject property hereby authorize tom— to act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION 1 ,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 behalf. Print Name Signature of Owner or Authorized Agent Date (Signed under the pains and 2enaltics of du 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 1 I0.116 and 110.R5, respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq. Ft.) (including garage, finished basemenUattics,decks or porch) Gross living area(Sq. Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of halfibaths 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" CITY OF SALEM PUBLIC PROPRERTY 3r, f - < DEPART'.vIENT III Y'8 '4 1'\V 778..'4},54� Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance �%ith the sixth edition orthe State Building Code, 780 CNiR section 1 1 1.5 Debris, and the provisions of'v1GL c 40, S 54; Building Permit It is issued with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c I 11. S 150A. The debris //will be transported by: (name of hauler) I he debris will be disposed /of inJ: l9l'�S��GY-� (6irT�tr (mm�r ul facility) (address u(laeility) signamrc of prnnit applicant ,late