7 LOCUST ST - BUILDING INSPECTION Microsoft Word-NEWPERMITFORM ITV 2 EAM1LY.doc- 1&2 Fam.. http://www.salenLcom/Pages/SalemMA_PublicProperties/application...
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Y� Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Ihtelling
This Section For Official Use Only
Building Permit Number: D
3 /3
Building Official(Print Name) - Signa Date'
SECTION 1:SITE INFO
1.1 Propert Address: 1.2 Ass rs p Parcel Numbers
7 ,c vcvJi
L la 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 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 a 402§54) 1.7 Flood Zone Information: 1.8 Sewn ge Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ovrner'ofRecord;
Name(Print) City,State,ZIPS
7 ZP007 Slr- �/�y-C CCon,�ll, X-1✓
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK"(check all that apply)
New Construction❑ Existing Building ❑ Owner-Occupied ❑ Repairs(,) ❑ Alteration(,) ❑ 1 Addition
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify.
BriefDescriptionofProposedWork'. J&i�IOYJ,El ,3 e�/f%/i/C/�O/�'!J� �(/ �i✓ /)il-w
/�%Iee/L/9�e�,1 //lc7rBClT !�✓ f/t �_P.��."fj,eb eoa-ir��
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials .
1.Building $ L Building Permit Fee: S 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 (HVAC) $ List:
5.Mechanical (Fire $ " . ..
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost:Is
i%f/ ❑Paid in Full [I Outstanding Balance Due:
6�
1 of 2- __ _ _ _M1512013.8:17 AM_
Microsoft Word-NEWPERMITFORM IND 2 FAMILY.doc- 1&2 Fam... hap://www.salemconl/Pages/SalemNIA_PublicProperfes/application...
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) ,3sr�y� 9aoly
��N License Number Expiration Date
Name o L Holder '/
List CSL Type(see below) //
No.and Street Type `' Description
�QR6Vd I' �� GO U Unrestricted(Buildings u to 35.000 cu.ft.
j�f/Jp R Restricted 1&2 FamilyDwelling
City/Tony.State; M Masonry
RC Routing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
97��/s�769 SH/j/�i9 �Dut@Ci9 �eT I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 1.5i2,7,
4 D UAI W HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name _
3' , /t�i/�2T / Jygyyr,�roi+lPCDr�so�fr,. 7
No.-anji Street Emad address
/"400yt A" pi9649
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'CODIPENSATION 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 ..........j? 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 fj�
to act(o77n my behalf,in all matters relative to work omed by this building permit application.
Print Owner's Name(Electronic Signature) Date
"SECTION.7bc O E r 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 application is,true and accurSIVto the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 nothave 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
ym .mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dus
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"
2 of 3/15/2013-8:17-AM—