1 KELLEY RD - BUILDING INSPECTION . � The Commonwealth of Massachusetts
� >� Boazd of Building Regulations and Standazds RECf I V CITY OF
Massachusetts State Building Code,�so c���PEC710Plq� S� SALEM
.�',Yd�rgr zol�
Building Permit Application To Construct,Repair,Reuovate QiJ�eA olish a
� One-or Two-Family Dwelling �0�5 UG 26
1'his Section For Official Use Only ,/ ,.r
J
- �--+ Build'mg Permii Number: Date �plied:
' � � ��
N Building O�cial(Print Name) Signanue Date
� � ^�ECTT03V 1:SITE IN�'ORNIATTOIV �
- l 1.1 Pr r Addressr 1.2 Assessors Map&Parcel Numbers
� � �if��, a�9
� l.la Is this an accepted street?yes no Map Number Paccel Number
1.3 Zoning Information: 1.4 Property Dimensions:
. Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(tt)
Front Yazd Side Yazds Reaz Yazd
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.4Q§54) 1.7 Flood Zone Informatim: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Check if yes0
SECTION 2: PROPERTY OWNERSHIP� '
21 Owner'ofRecor�: j� t /j C _,�� �5
.�! '�lf�w t j'�r ._JorK�.l��sol'� -.�ar
Name(Prin City,State,ZIP j
9�-a3q-Na6�f
� No.and Street Telephone - - ' Email Address
SECTION 3:DESCRIPI"ION OF PROP03ED WORIC'(eLeck all that apply)
� � New Constrvction❑ Existing Building Owner-Occupied�'{( Repairs(s) Alteration(s) 1� Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units� Other ❑ Specify: �
B�ief Description of Proposed Wor : i Y �
O /'C'� � . i � � �
� ,, en : fJ
- � � � e
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs �
Item Ot'Scia1 Use Only
Labor and Materials �
1.Building $ �Q 1. Buildin ee: 'cate how fee is determined:
2.Electrical $ �' �.� � . � .dazd City/Town Application Fee
Total Project Cost3(Item 6)x mulYiptier x
�• 3.Plumbing $ �Qpa 3. Other�es: /"�� —
,. 4.Mechanical (HVAC) $ List: `,:� 1. - .
r 5.Mechanical (Fire $ _ �
Su ression es;$
� Check No. Check Amount: Cash Amount:
6.Total Project Cost: $a�OOQ ❑Paid in�L19 ❑Outstanding Baiance Due:
��r � I � 1
�'�0�1`�1 �o�rd ���,
�/���3�,��� � �� '���
SECTIQN 5: CO�TSTILUCTION SERVICES
5.1 Construction Supervisor License(CSL) '
License Number Expiralion Date
Name of CSL Holder �
� List CSL Type(see below)
No.and Street ' .TypC - , .. p. �� , .� �:
..�. - DeScri tuxi.
U Unreshicted uildin u [0 35,000 cu.R��
� R Restricted 1&2Fami1 Dwetin
City/1'own,State,ZIP M Maso
RC RooSn Coverin
WS Window and Sidin
SF Solid Fuel Buming Appliances
I Insu]ation .
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(filC)
HIC Company Nazne or HIC Registrant Name HIC Registration Number E�cp'vation Date
No.and Street Email address
Ci /Town,State,ZIP � Tele hone
SECTIOIV 6:WOIiKERS'CUMPENSATION IN�CJI2ANCE AFN7DAVIT(M.G.L c:152.§25C(6�) `�
Workers Compensation Insurance affidavit must be completed and submitted with this applicafion. Failure to provide�
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No........... ❑
SECTTDN 7a:O�'�LERADTHORTZATTO�T TO BE CO3ktPLETED WHEN T "
r,„
" � OWN.ER'S AGENT.OR C4NTRAC3'OR APR3,IE5 FOR BIIII,DIlw6 PER3YIiT ; �
I,as Owner of[he subject property,hereby authorize���i.�f+r..v�. �O � ��
to act on my behalf,in all matters relafive to work authorized by this building permit applicaUon.
�u �/% R M � tiR ...,, �=�-/ s'
Pnn[Owner's Name(Electronic Signature) Date
SEC1`ION'3tic OWNER'ORAUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
c ntained in this application is lrue and accurate to the best o owledge and understanding.
I i�r� � �. /4 � �.'t � CJ ' Ci� �/J
nnt Owner's or Authorized AgenYs Name(Electronic Si�atw�e)� Date
. .,� � , _� � . :
T � , "'_ 'NOTESi '�_ � � „, _ . �� � -
]. 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 azbitration -
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
�a�vw.mass.>ot, v.'oca Information on the Canstruction Supervisor License can be found at w��•w.mass.gov/d�
. 2. When substantial work is planned,provide the information below:
Total floor azea(sq.ft.) (inciuding gazage,finished basemenUattics,decks or porch)
Gross living azea(sq.ft.) Habitable room count 5 ��
Number of fireplaces ) Number of bedrooms �, -
Number of bativooms � Number of half/baths �
Type of heating system � Number of decks/porches
Type of cooting system Enclosed Open �_._
3. "Total Project Square Footage"may be substituted for"Total Project CosY'