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The Commonwealth of Massachusetts ED
O ' g Board of Building Regulations and Standards INSPECf10NA SFIMg F
Nafi Massachusetts State Building Code,780 CMR �1l 't nnFFrr SALEM
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Building Permit Application To Construct,Repair, Renovate Or 18 pvtW 2011
One-or Two-Family Dwelling
1 This Section For Official Use Only .
Building Permit Number: Date Ap 11
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( Building Official(Print Name) Signature
- SECTION 1:SITE INFORMATION
1.1 Propert
12 y Address//r ,rt / 1.2 Assessors Map&Parcel Numbers
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1.1 a Is this an accepted street?yes_ rio Map Number Parcel Number
1.3 Zoning Information: 1,4 Property Dimensions:
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) LT Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 0 err of Recg�d
Jt ( P L'oSZs Ja�ZN�I ky+
Name(Print) City,State,ZIP
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12 Lo," l ,.� lFLZ- 7o7- �SG6
No.and Street Telephone Email Address
SECTION 3:DESCRI iiTION OF PROPOSED WORE:(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ L Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ ! Number of Units_ Other Specify:
Brief Description of Proposed Work : i
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SECTION 4,ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials Official Use Only
1.Building $ a—7 Q J - 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ i ❑Standard City/Town Application Fee
❑Total Project Costa(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: $
o ❑Paid in Full ❑Outstanding Balance Due:
NAB I zl « r
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 7 -7-7 y
License Number Expiration Date
Name of CSL Holder
Eric W. i,;hll - List CSL Type(see below)
No.and Street Type Description -
Salem MA 0"1970 U unrestricted(Buildings up to 35,000 cu.13
R Restricted 1&2 F Dwelling
Cityfrown,State,ZIP M Mason
ry
RC ko o I ing Coyerin
WS Window and Siding
C 'r t 5 SF Solid Fuel Burning Appliances
1 _/ I 1 Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC) ' i lie
Atlantis WBe hezizattttn I W HIC Registration Number Expiration Date
HIC Company Name or HICRe¢i a NameVet1Ue
No.and street Ol Salem MA 01970 Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.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 CONTRACTOR`APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize C.,Imo; I
G Ca !yn
to act on my behalf,in all matters relative to work authorized by this building permit application.
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Print Owner's Name(Electronic Signature) i Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in gthi ppI' .i s true curate to the best of my knowledge and understanding
Y 9 i t
Pant Owner's or Authorized Agent's Name(El"nic Signature) Date
i NOTES:
1. 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.LI c. 142A.Other important information on the HIC Program can be found at
www.mass:ovtoca Information on the Construction Supervisor License can be found at www.mass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) i (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�substi[uted for"Total Project Cost"
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