106 LEACH ST - BUILDING INSPECTION (4) 4\ The Commonwealth of Massachusetts
Board of Building Regulations and Standards . CITY OF
Massachusetts State Building Code,780 CMR SALEM
Building Permit Application To Construct,Repair, Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
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SECTION 1:SITE INFORMATION
1.1 Properly Addre 1.2 Assessors Map&Parcel Numbers
/. St UN tT- Z
1.1 a Is this an accepted street?yes_ no_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Pm_posed Use
Po Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
EEReturedE Provided E Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.-Sewage Disposal System:
Public❑ Private❑ Zone: — Outside Flood Zone?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTYOWNERSIID''
2.1 Owner'of Re rd
Nam fete �Q r1 �u N Ca Sale, �19 o/9a �7
City,State,ZIP
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No.and Street Telephone Email Address _
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
fJ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other Specify:_�rr/a
Brief Description of Proposed Work: S
SECTION 4:ESTIMATED CONSTRUCTION COSTS \ \
Item Estimated Costs:
Labor and Materials Official Use Only
1.Building $ 00 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 (WAC) $ List:
5.Mechanical (FireSuppression) $ Total All Fees:$
6. Total Project Cost: $ Check No. Check Amount. Cash Amount:
3Uab ' ❑Paid in Full ❑Outstanding Balance Due:
I 1,
SECTION 5:. CONSTRUCTION SERVICES -
5.1 Construction Supervisor License(CSL) 9 7 9-7 -7
Name of CSL Holder License Number Expiration Date
Eric W. Palm List CSL Type(see below) ( {
No.and Street H11t011��gg( T
- TPe Description,
Sa em MA 01970 U Unrestricted uildin s up to 35,000 cu.ft.)
C,ty/I'own,State,ZIP R Restricted 1&2 FamilyDwellinjz
M masonry
RC Roofin Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
I 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(RIC) I 0 J 2//Z /
Atlantic W ath ri�ation T If HIc Registration Number Expiration LI H1C Company Name 06 PW Yffi 3iMenueDate
No.and Street Sa ern MA 01970 Email address
Ci /Town,State,Z[P 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 Issuanc the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 70:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIESFOR BUILDING PER
I,as Owner of the subject property,hereby authorize (/r,C- cc! /W7
to act on my behalf,in all matters r(�ellativvne to work authorized by this building permit application. /
Pent Owner's Name(Electronic Signature) V Date
SECTION 7b:OWNEW 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 this appli n is d accurate to the best of my knowledge and understanding.
Print Z
Owners or Authorized Agent's Name(Electronic Signature) 3 Datee
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 no 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.eov/oca 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.) (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 substituted for"Total Project Cost"