1 MALL ST - BUILDING INSPECTION (5) i
1
The Commonwealth of Massachusetts CITY
hoard of Building Regulations and Standards OF SALEM
Massachusetts State Building Code, 730 CMR, 7"edition RevisedJunuury
Building Permit Application'ro Construct, Repair, Renovate Or Demolish a /. 2008
YYYY One-or Tsro-Family Dwelling
This Section For Official Use Onl
:Building2Pennit b Date Applied:
i
u mi: t e Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map 8t Parcel Numbers
I.1 a Is this an accepted street'?yes VMa/ no. P Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq IU Frontage(M
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Requited 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? Municipal 13 On site disposal system ❑
Public❑ Private❑ Check if es[3
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owners of Record:
n4lTtttt�
y um riot (\'�(/ Address 1'or Service:
Signature 'telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repatrs(s) ❑ 1 Afteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': �
X4:;1V—FK (° ome v -•!0 5✓N6GE• Fr4Mlf%Y
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials
1. Building S (&,�ycr o I. building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical p v ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S p d d v 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Suppression)
Check No. Ch`ck Amount: Cash Amount:_
x 6.Total Project Cost: S Q,p'r 0m 43 ❑Paid in Full ❑Outstanding Balance Due:
0
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! or a y emv
L .1 C r�
r
SECTION S: CONSTRUCTION SERVICES
5.1 C-�rmbuetlun:SSL)
/y� I,1
x1f License Number Expiration Uate
Na mr of ' I older List CSL 1)pe(see below)
rZ, r� Description
`y ��f�'h �i/.Cf. �/9�� 11 1 1InmtricteJ(up to 35.000 Cu. Ft.)
Signature r R Restricted 1&2 Family Dwelling
M I Masonry Only
RC ResiJcntia,1 Rootin Co%crin
Telephone WS Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Namc or I IIC Registrant Name Registration Number
Address
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 7a: 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
1, as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
X behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of du
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(IIIc)Program),will Ligot have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.R5,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.) Ilabilable 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 (inclosed Open
3. "Total Project Square Footage-may he substituted lir"Total Project Cost"
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