4 KING ST - BUILDING INSPECTION ,p M6 The Commonwealth of'Massachusetu
I 't Board of Building Regulations and Standards CITY
/ y . ' u OF SALEM
( Massachusetts State Building Cole, 780ZMRedition
� Revisal Jmnnrrr
Building Permit Application To n rucl, Repaiatc Or Demolish aOne-or wo- mily Dwell
"A Section For OITic' Use Only
Building Pe Nu/�mber. Dat Applied:I / k i Signature: � -x, Y oJd ,/ (�
Budding Commis ones/Inspector o 5
Buildi Date
SE 1: SITE INFORMATION
1.1 Pro fl tyYAd ress+ 1.2 Assessors Map& Parcel Numbers
1.la Is this an accepted street?yes no Map Number Parcel Number
IJ Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Am(sq 11) Frontage(11)
1.5 Building Setbacks(R)
From Yard Side Yards Rear Yard
Required Provided Required Provided Requited Provided
1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Publi5lik Private❑ Zone: _ Outside Flood Zone' Municipal
Check if ew&C' r On sita disposal system ❑
r
SECTION 2: PROPERTY OWNERSHIP"
2 1 Owner'of Record: 4 r1 t° "� 5 �k-
JNs/�
Nome 1 ) Address rot Service:
Signal Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Buildin Owner-Occupied 1K Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.W Number of Units_ I Other ❑ Specify:
Brief
Description of Proposed ° t O J� p` q/
� e on s4 s r In rr SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OfOclal Use Only
Labor and Materials
I. Building S /0 Q'LS, Oa 1. Building Permit Fee: f Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
). Plumbing S �� 2. Other Fees: S
4. Mechanical (BVAC) S —� List:
3. Mechanical (Fire S Suppression) Total All Fees:S
6. Total Project Cost: S J g �S, O� Check No. _Check Amount: Cash Amount:
/ ❑Paid in Full O Outstanding Balance Due:
r
SECTION 5: CONSTRUCTION SERVICES
S.,Llcensecl ansiructlon Supervvisor(CSL) CS , p ��Zt f Z ►(p Zo 13
O� u F i14 V� �J—� I.icerue Number Expiration IMe
N of SL•Ilulder flu I.isICSL-fype(seebelowl
ouc
y
f I Ixscri ion
"�u/2(�� jGr /S— U I tlnresuicted(up to 13,000 Cu.Ft.
Restricted IR2 Family D%ellin
Si to M I Mmonry only
RC I Residential Routing Covering ;
Nlcplrule I WS I Residential Window and Siding
, SF Residential Solid Fuel Burning Appliance Installation
p
f Z 8 96�( r ? S-5_ D Residential Demolition
vemest Co netor IC �'
s��K Ic�t h d- m�'e/��� 2 !� 7 .
I IW CorgpanY NiYlr�ur HIC,Ite�st Name - Registration Number
55 C5 �� K) q� >� �61 zco/ �ot �
ied-e7 S 9 Expiration Date
Signature Telephone
SECTI N 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a IS2. f 2SC(6))
Workers Compensation Insurance alrtdavil 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 ..........V' No...........O
SECTION 72:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 'o{�Vie- �� n -so as Owner of the subject property hereby
authorize dD rr Pr e4 yl to act on my behalf,in all matters
relative I ork authorized by thia ildin rmit application.
je /6 / 2 �/ Zola
ISianature of Owner Date
SECTION 7b:OWNEWORRAUTHORIZED AGENT DECLARATION
1 Z Co c ('�h --III—� ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are We and accurate,to the best of my knowledge and
behalf.
Print Nampa
Signature of Ow or Authorized Agent Date
Mitred under the pains andpimaltics ofperjury)
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 rM have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations 110.R6 and 110.R3,respectively.
2. When substantial work is planned,provide the information below:
Total (loon area(Sq. Ft.) (including garage, finished basement/anics,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
). "Total Project Square Footage"may be substituted 1'or"Total Project Cost"