0009 LINDEN AVE - BPA-16-1240 HVAC - DUCTWORK 09/29/2011 13:05 9787409846 CITYOF SALEM PAGE 01/02
n
9
Commonwealth of Massachusettr3,��f-li.�r
�
Sheet Metal Permit
2% OCT 25 A II: IQ
I)atu: 1 C� Zl f CP 1'crmit#
-S� INtimated Job Cost: $ 25d C7 Purmit Feu: $ 2-5 l Cr-� o_ o z-g SZ3l
111uts Submitted: YES _ NO _� Plans Reviewed: YES_ NO _
Business Liccnsc # / Applicant License# 2 9/ Z __
Business Information: Property Owner/Job Location Information.
Name: S'J'ln (® t ( Name: -- ' `�/4 _ t -c—
Street: I 4Py3, is i-R Street: — - - (sr .A� ay-�
City/Town: G��d City/Town:
Telephone: r! / Telephone:
Photo t• op to I.D.attached; YES—�NO—
swrr tmnat
J-t / tt-I-unrestricted license 5I I rD-E - ot✓ DES 2�' M-7
J-21 NW-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. R. /2-stories or less
Residential: 1-2 Family Multi-family_ Condo;/Townhouses_ Other_
C'ommurcinl: Office— Retail_ Industrial Educational
Institutional Other
Square Footage: under i0,000 sq. ft. i✓ over 10,000 sq. 11, _ Number of Stories: _
Sheet utetal work tobe completed: New Work:— Renovation:
I IVAC ✓ vietal W;ttershed Rooling_ Kitchen Fshaust Systcm_
Metal Chimney/ Vents_ Air Balhncing
Provide dCU1iled dcscriptinn of work to be done:
Q C� ✓t��� c7 t)ot� �C �b tl �i'-C — 42 )Cft' ,. rt ._
ire
- as The Commonwealth of Massachusetts ±ice
Board of Building Regulations and Standards `%ry OF
SALEM
l ) Massachusetts State Building Code, 780 GM OCT 25 A j :t"ed Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date.Applied. -
Building Official(Print Name) - Signature Date
SECTION.1:SITE INFORMATION
1.1 Property Address:Imo 1.2 Assessors Map&Parcel Numbers
�! 1n — �2n 06 `40
1.Is Is this an accepted street?yes no Map Number Parcel Number
1.3 Zo:2 Information: 1.4 Property Dimensions:
Zoning Distrief Proposed Use Lot Area(sq ft) Frontage(It)
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 ElOn site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Re d: �7
etrrti t GLC c [a-U—m , ✓Y1OL o
Name(Print) - . City,State,ZIP I
No.and Street L( � Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
l QJ
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials
1.Building $ 1 Building Permit Fee. $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ m -
Total Project Cost'(item 6)x.multiplier x -
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ a 665 List
5.Mechanical (Fire $
Suppression) Total All Fees.$
Check No. -. Check Amount: Cash Amount:
6.Total Project Cost: $ 0 Paid in.Full 0 Outstanding Balance Due:
r SECTION 5: CONSTRUCTION SERVICES -
5.1 Construction Supervisor License(CSL) l I Z /` &P
`?� mRs Ca,..►��uj License Number Expiration Date
Name of CSL Holder `c�
List CSL Type(see below) V
� Y
No.and StreetH Type Description
U Unrestricted(Buildings u 35,000 cu.ft.)Ci /Town,State ZIP /�'1• R Restricted Family
tcd 1&2 amil Dwelling
t3' Masonry
aso
RC Roofing Coverin
WS Window and Siding
p .0 �/� SF Solid Fuel Burning Appliances
�-7
! S( -j V I ik Q 05 I Insulation
Telephone Em it address ir D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State,ZIP 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 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
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTIONI7b: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 this appl rtion is true andd curate t the best of my knowledge and understanding.
Print Ow s Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. 6dOwner 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. og v/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 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"