7 LOCUST ST - BUILDING INSPECTION (2) t ..
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
I li Massachusetts State Building Code, 780 CMR, 7ih edition OF SALEM
Revised January
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, '008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Pertnit mbe : Date Applied: Zi •2,?•
Signalur
il ' Com 'is'ioh I •torof Buildings Date
SECTION 1:SITE INFORMATION
I.1,7r>Propporerty tAddress: ' 1.2 Assessors Map& Parcel Numbers
u sT T
L l a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(11)
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 Record:
C t rn 1.v i L,,--> e " sT S-I—
Name(Print) Address for Service:
9 -78 -7 3y6 q
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
- New Construction❑ Existing Buildin Owner-Occupied Repairs(s Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ I Number of Units Other ❑ Specify:
Brief Description of Proposed Work': .S T tZC b R oQF.L
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S 2 00" I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) $ List:
5. Mechanical (Fire S
Su ression Total All Fees: S
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S �� Q Oc> 13 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) O 4 y-7 A 3
k 2 � ob6I":A, License Number Expiration Uate
Name of C'SL-I folder List CSL Type(see below)
.i r Description
•oddn�s U Unrestricted(up to 35,000 Cu.Ft.
- R Restricted 1,@2 Family Uweliin
Signature M Mason Only
`'� g 3 �- �� RC Residential Routing Coverin
'Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 ement Registered �ne Imbprov �pntractor(HIC) 1
L.p� Crt oZ r ( c�✓T
HIC um an Name ur f11C&egistrant Nam Registration Number
Add � Expiration Date
Signature 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 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1. 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.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
Cr- t k- L Ir— C evn 1� ,as Owner o uthorized Agen ereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name � _ `Z3 —� D
Signature of Owner o uthonze Agen - Date
(Signed under the pains and enalties o perjury)
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 gol 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 780 CMR Regulations 110.116 and I IO.RS,respectively.
?. When substantial work is planned,provide the information below:
Total floors 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"