8 LOCUST ST - BUILDING INSPECTION (4) n
�J The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7"edition OF SALEM
�VVY 'wsr Revised Jmwury
- Building Permit Application To Construct, Repair, Renovate Or Demolish a i. 1008
1Vt, One-or Tivo-Family Dwelling
This Section For Official Use Only
Building Permit Numb r• Date Applied:
Signature: q • 27 - I c�
Building Commis io a pector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 roperty Address: 1.2 Assessors Map& Parcel Numbers
Lr�c.vST C
I.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 11) Frontage(11)
1.5 Building Setbacks(it)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.t Owner'of Record:
�-- fit--o rc-Y g ( O e v 3
Name(Print) Address for Service:
CY'Z Z3 -1 y 5 -7 3 5 L
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Buildi Owner-Occupie epairs(s Iteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units I Other ❑ Specify:
Brief Description of Proposed Work': F —h— Q. ;2pto
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building S cuC _ I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard Cityrrown Application Fee
❑Total Project Costs(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (BVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
p �p Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S ) -]s 0 Paid in Full 0 Outstanding Balance Due:
r
f
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) D 9 y 7 -14J 4_ to
TS jp b b> License Number Expiration Date
Name of CSL-I lulder List C'SL'rype(see below)
o a S-r PEA b��
T Description
Addrcsi-�- �` U Unrestricted(up to 35.000 Cu.Ft.
R Restricted l&2 Family Dwelling
Si murc M Mason Only
�J" 3 D rt-�l y RC Residential Roofing Covering
relcphone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Regbtered Ho Improvement r7gntractor(HIC)
j�,pti r �� l--O�✓T' Registration Number
HIC Company Name or tI ICRegis�(ant N
AJJ sr�s _ Q�•_o �j,�� ,5.��•n�
Expiration Dale
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...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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: OWNER'OR AUTHORIZED AGENT DECLARATION
C as Owner o Authorized Agent reby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf..
Print Name
-ZS-- (7
Signature of wnero uthoriz n Date
Si red under the airs and enalties o per,
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 mot 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.R6 and I IO.RS,respectively.
2. 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"