3 KING ST - BPA The Commonwealth of Massachusetts CITY OF
` Board of Building Regulations and Standards SALEM
I,1►1 Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
r 1 This Section For O#iOal Use Only
Building Permit Number: D to Applied:
�O
Building Official(Print Name) ' ,Signature - ''Date
^ t, SECTION 1:SITE INFORMA
1.1 Pro�jperty Address: 1.2 Assessors & Parcel Numbers
� ✓- S(�G ,S'� ' � I Ste(
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Informatio :. (1 i 1.4 Property Dimensions:
A� i to nk
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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 if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of cord- II
c� A IKA0 Nary s A \-e,a,. 61
Name,, �
(Print) City,State,ZIP
'9 K014 L - ?g( - ?GLj- g6i)1
No.and Streef Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORIO(check all that apply) _
New Construction ❑ Existing Building Owner-Occupied Repairs(s),40 I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units Other Jil Specify: ko
Brief Description of Proposed Workz: Kc oo
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: '
Item Official Use Ouly .
Labor and Materials -
1.Building $ U Cl ( 1. Building Permit Fee:$ Indicate how_ fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
❑Total Projeci Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees:"$ -
4.Mechanical (HVAC) $ List:
5. Mechanical (Five $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ '41 dU 13 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
,Tf-SS p n 2 �G SoLicense Number EypDatt nIse Name of CSL Ho der
List CSL Type(see below) '
No. and Street -Type Description ,
U Unrestricted(Buildings up to 35,000 cu. ft.
t'ry^Y �W yvw l� 0 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
rr�� �I SF Solid Fuel Burning Appliances
'J S`-AdOO Jc JT Jrt�g`� I I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
c e l A �e I`�a$n
zll 10
HIC Registration Number Expiration Date
HIC Compan Nam or IC Registrant Name
ib� 8� e=ts _r
Ad
No. d S e [ o Email address
1uo� . on� r VIA �s >1 SyB 3�1—��c�
City/Town, State,ZIP Telephone SY f-
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 CONTRACT—O�R�APPLIES FOR.BUILDING PERMIT. . F
I,as Owner of the subject property,hereby authorize Jb.S�O� C ern
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7bi;OWNER' OR AUTHORIZED AGENT DECLARATION - g,
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this ap at' and accurate to the best of my knowledge and understanding.
Print Owner's or A orized Agent's Name(Electronic Signature) Date
NOTES:
1. An er 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 can be found at
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor 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 haWbaths
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" j 4.GU